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GIFT   OF 


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HANDBOOK 

OF 

CHILD  HYGIENE 


As  civilization 
£oes  dovn  the 
baby  death  rate 


LYDIA  ALLEN  DEVILBISS,  M.  D.,  DIRECTOR 
DIVISION  OF  CHILD  HYGIENE 

KANSAS  STATE  BOARD  OF  HEALTH 
TOPEKA 

7-4194 


y\ 


BULLETIN  OF 

The  Kansas  State  Board  of  Health 

S.  J.  CRUMBINE,  M.  D.,  SECRETAEY. 
Published  monthly  at  the  office  of  the  .'^cretary  of  the  Board,  Topeka,  Kan. 

VOL.  XIV,  Nos.  8  and  9.          TOPEKA,  KAN.  Aug.  arid  Sept.,  1918. 

Entered  as  second-class  matter,  March  5,  1906,  at  the  post  office,  Topeka,  Kan.,  under  the 
act  of  Congress  of  July  16,  1894. 


CONTENTS. 

The  President's  Letter. 

Results  of  the  Draft  Examination. 

The  Significance  of  the  Declining  Birth  Rate. 

Infant  Mortality. 

Studies  in  Infant  Mortality. 

Reduction  of  the  Infant  Mortality  Rate. 

School  Hygiene. 

The  Child  Wards*  of  the  State. 

Child  Welfare 


.;  T  ;    ^j^ ,5. 


(COPY.) 

THE  WHITE  HOUSE,  WASHINGTON. 
My  Dear  Mr.  Secretary: 

Next  to  the  duty,  of  doing  everything  possible  for  the 
soldiers  at  the  front,  there  could  be,  it  seems  to  me,  no 
more  patriotic  duty  than  that  of  protecting  the  chil- 
dren, who  constitute  one-third  of  our  population. 

The  success  of  the  efforts  made  in  England  in  behalf 
of  the  children  is  evidenced  by  the  fact  that  the  infant 
death  rate  in  England  for  the  second  year  of  the  war 
was  the  lowest  in  her  history.  Attention  is  now  being 
given  to  education  and  labor  conditions  for  children  by 
the  legislatures  of  both  France  and  England,  showing 
that  the  conviction  among  th$  Allies  is  that  the  protec- 
tion of  childhood  is  essential  to  winning  the  war. 

I  am  very  glad  that  the  same  processes  are  being  set 
afoot  in  this  country,  and  I  heartily  approve  the  plan 
of  the  Children's  Bureau  and  the  Woman's  Committee 
of  the  Council  of  National  Defense  for  making  the  sec- 
ond year  of  the  war  one  of  united  activity  on  behalf  of 
children,  and  in  that  sense  a  children's  year. 

I  trust  that  the  year  will  not  only  see  the  goal  reached 
of  saving  one  hundred  thousand  lives  of  infants  and 
young  children,  but  that  the  work  may  so  successfully 
develop  as  to  set  up  certain  irreducible  minimum 
standards  for  the  health,  education  and  work  of  the 
American  child. 

Cordially  and  sincerely  yours, 

(Signed)        WOODROW  WILSON. 


398582 


116  Kansas  State  Board  of  Health. 


Results  of  the  Draft  Examination. 

"It  is  not  an  army  we  must  shape  and  train  for  war,  it  is  a  nation." — President  Wilson. 

Report  of  the  Provost  Marshal  General: 

Total  men  called  by  draft 3,802,946 

Total  examined  by  loeal  boards 2,510,706 

Total  rejected  by  local  boards  for  physical  reasons      730,756 

Percentage  of  those  examined  rejected 29.11 

Add  5.8  percent  rejected  at  cantonments    (esti- 
mated)              33.11 

There  is  no  disputing  these  figures.  There  is  no  sentiment 
attached  to  them ;  they  are  the  cold  facts  obtained  by  military 
machinery.  If  one-third  of  American  manhood  between  the 
ages  of  21  and  31  is  so  physically  defective  as  to  be  rejected  for 
military  service,  what  is  to  be  expected  of  those  under  21  and 
past  the  age  of  31?* 

The  most  superficial  analysis  of  the  causes  for  which  men 
are  rejected  for  service  shows  that  more  than  60  percent  of 
these  defects  are  preventable ;  that  30  percent  are  due  to  poor 
general  physical  condition,  which  can  be  remedied  by  proper 
feeding,  by  proper  attention  to  personal  hygiene  and  physical 
training ;  that  another  30  percent  are  due  to  defective  eyes  and 
teeth,  including  bad  mouth  conditions;  and  that  only  10  per- 
cent are  due  to  neglected  surgery. 

An  analysis  of  the  purely  preventable  defects  for  which 
these  men  have  been  rejected  shows  that  they  are  not  acute  or 
of  recent  occurrence,  but  that  they  are  chronic  conditions— 
that  is,  they  have  existed  for  years,  many  of  them  from  early 
childhood.  A  little  more  attention  to  the  physical  needs  of 
children,  correction  of  their  minor  defects  while  they  are  still 
easily  remedied,  and  proper  health  protection  of  the  growing 
boys  and  girls  would  result  in  a  very  different  health  and 
efficiency  analysis  of  the  adult  population. 

With  these  figures,  is  there  any  further  argument  needed  as 
to  the  value  of  child  hygiene  and  of  the  necessity  of  pushing 
health  protection  to  include  all  citizens  ? 

*  Dr.  Eugene  L.  Fiske,  Journal  of  the  American  Medical  Association. 


Bulletins  Nos.  8  and  9,  August-September,  1918.        117 


The  Significance  of  the  Declining  Birth  Rate.* 

The  study  of  American  demography  reveals  a  problem  of  the  greatest 
possible  moment.  Changes  have  been  progressing  in  the  internal  struc- 
ture of  our  population  which  have,  for  the  most  part,  escaped  attention 
and  which,  if  allowed  to  continue,  will  result  in  very  serious  national 
embarrassment.  Conditions  of  war  bring  into  relief  the  necessity  for  a 
vigorous  and  efficient  population.  It  is  not  too  much  to  say  that  the 
present  tendencies  in  our  national  and  family  life  are  such  as  seriously 
threaten  the  development  of  groups  in  the  population  on  which  we  must 
rely  for  vigor  and  efficiency  in  thought  and  action. 

Superficially  the  growth  of  American  population  at  present  appears 
to  be  very  satisfactory.  Each  census  shows  a  marked  increase  in  total 
population.  Our  birth  rate  is  probably  about  25  per  1,000,  and  the  death 
rate  for  the  entire  country  not  far  from  15  per  1,000.  The  difference 
between  the  birth  and  the  death  rate,  the  rate  of  natural  increase,  is 
about  10  per  1,000,  or  one  percent  annually.  On  the  surface  this  is  a 
very  good  showing.  It  is  when  we  observe  the  varying  tendencies  in  the 
several  groups  and  in  the  several  sections  of  the  country  that  the  real 
situation  becomes  apparent. 

The  marked  increase  in  our  total  population  is  in  large  measure  the 
result  of  two  factors:  (1)  immigration,  and  (2)  a  high  rate  of  increase 
among  the  foreign-born  rather  than  among  our  native  stock.  This  is 
shown  by  the  constantly  decreasing  proportion  which  the  native  whites 
of  native  parentage  form  of  the  total  white  population.  This  decreased 
from  67.8  percent  of  the  whole  in  1870  to  60.5  percent  in  1910.  In  the 
New  England  states  the  proportion  of  native  white  stock  decreased  from 
52.3  percent  of  total  in  1890  to  40.3  percent  in  1910.  In  the  Middle 
Atlantic  states  the  native  white  stock  decreased  from  51.8  percent  in 
1890  to  44.5  percent  (or  less  than  half)  in  1910. 

Native  stock  is  playing  an  even  smaller  part  in  the  composition  of  the 
total  population  and  a  very  definite  tendency  toward  depopulation  has 
already  fastened  itself  upon  a  large  part  of  the  native  stock  of  the 
country. 

There  has  been  a  marked  and  continuous  reduction  in  the  general 
birth  rate  in  the  United  States  for  a  period  of  years.  In  the  absence  of 
comprehensive  birth  statistics,  such  as  are  available  for  European  coun- 
tries, we  may  arrive  at  this  through  computing  the  number  of  children 
under  five  years  of  age  per  thousand  women  in  the  child-bearing  ages, 
namely,  15  to  44  years,  inclusive. 

Professor  Willcox  in  a  recent  paper  has  shown  that  this  proportion 
has  decreased  about  50  percent  in  the  course  of  the  last  hundred  years. 
At  the  beginning  of  the  century  there  were  976  children  under  five  for 
every  thousand  women  between  the  ages  of  15  to  44  years,  whereas  in 
1910  the  number  was  only  508  per  thousand  women  at  these  ages.  Dur- 

*  From  an  address  delivered  by  Louis  I.  Dublin  before  the  American  Association  for 
Advancement  of  Science,  December,  1917. 


118  Kansas  State  Board  of  Health. 

ing  the  60  years  between  1850  and  1910  the  number  of  children  under 
5  per  thousand  women  at  the  child-bearing  ages  decreased  in  the  United 
States  by  191,  or  at  an  average  of  32  in  each  decade.  The  rate  of  decline 
in  the  recent  decades  has  been  so  rapid  that  Professor  Willcox  suggests, 
amusedly,  that  if  it  were  continued  over  a  period  of  a  century  and  a  half, 
which  is  comparatively  short  time  in  the  life  of  a  nation,  there  would  be 
no  children  at  all  at  the  end  of  that  time. 

This  reduction  in  birth  rate  has  been  severely  selective  and  has  af- 
fected mostly  our  native  stock,  and  among  these  especially  the  groups 
who  are  socially  and  economically  best  fitted  to  bear  and  rear  large  fam- 
ilies to  maturity. 

A  tabulation  of  the  1910  census  returns  shows  that  women  of  native 
parentage  who  had  been  married  from  ten  to  twenty  years  showed  an 
average  of  2.7  children,  while  the  corresponding  group  of  foreign-born 
women  averaged  4.4  children  per  married  woman.  Thirteen  percent  of 
the  group  of  married  women  of  native  stock  had  borne  no  children, 
while  only  5.7  percent  of  the  foreign-born  group  were  childless. 

Additional  evidence  of  the  selective  character  of  the  declining  birth 
rate  is  presented  in  special  studies  on  the  size  of  families  of  college 
graduates  and  men  of  science.  The  birth  rate  among  graduates  of 
Harvard  and  Yale  during  the  decade  between  1850  and  1860  was  3.25; 
for  the  decade  1880-'90  it  was  a  little  over  2.  The  number  of  children 
per  married-woman  graduate  of  Smith  College  was  1.3;  of  Vassar  1.6; 
of  Bryn  Mawr  1.7;  of  Holyoke  1.8.  The  ratio  of  children  per  graduate 
for  all  of  those  colleges  is  less  than  one,  due  to  the  fact  that  less  than  50 
percent  of  graduates  of  women's  colleges  marry.  According  to  Professor 
CattelFs  study  of  the  families  of  643  American  men  of  science,  they  had 
come  from  families  averaging  4.7  children,  while  their  own  families 
averaged  only  2.3  children. 

Allowing  for  sterile  marriages,  child  mortality,  and  failure  to  marry, 
it  is  estimated  that  productive  unions  must  average  at  least  four  children 
in  order  to  maintain  the  population  at  a  stationary  figure.  It  will  be- 
come readily  apparent  that  the  best  blood  of  America  is  being  constantly 
thinned  out  and  replaced  by  a  stock  of  a  different  order. 

Remedy:  1.  Inculcate  the  ideal  into  our  educational  life  that  our 
intellectual,  economic  and  social  advancement  must  be  carried  forward 
not  only  as  tradition,  but  especially  in  terms  of  new,  vigorous  and  worthy 
personalities. 

2.  Reconstruct  our  higher  education  for  women  and  make  it  provide 
primarily  an  adequate  conception  of  and  preparation  for  the  vocation 
of  motherhood. 

3.  State  reward,  both  by  esteem,  and  by  subsidy  when  necessary,  of 
all  healthy  and  eugenically  sound  families  which  reach  or  exceed  the 
normal  size. 


Bulletins  Nos.  8  and  9,  August-September,  1918.        119 


Infant  Mortality. 

The  term  infant  mortality,  used  technically,  applies  to  death  of  babies 
under  one  year  of  age. 

The  infant  mortality  rate  is  the  statement  of  the  number  of  the  deaths 
of  such  infants  in  a  given  year  per  live  1,000  births  in  the  same  year.* 

The  infant  mortality  rate  is  considered  the  most  sensitive  index  we 
possess  to  social  welfare.  It  reflects  at  once  conditions  which  improve  or 
interfere  with  the  normal  health  or  life  of  the  community.  As  condi- 
tions which  make  for  a  nortnal  family  and  community  life  are  improved, 
the  infant  death  rate  decreases.  When  these  conditions  are  disturbed, 
the  rate  correspondingly  increases.  The  infant  mortality  rate,  therefore, 
may  be  taken  as  the  barometer  of  the  social  welfare  of  the  co/mmunity. 

The  state  of  Kansas  enjoys  a  relatively  low  infant  mortality  rate  com- 
pared with  other  states.  According  to  the  birth  statistics,  Bureau  of 
Census,  for  the  birth  registration  area  for  1915  (the  latest  figures  avail- 
able),  the  highest  state  infant  mortality  rate  was  129  and  the  lowest  69. 

The  division  of  Vital  Statistics  of  the  State  Board  of  Health  was  es- 
tablished in  July,  1911.  The  Division  of  Child  Hygiene  was  established 
in  July,  1915. 

The  Kansas  infant  mortality  rates  for  the  period  for  which  records  are 
available  are  as  follows:  1912,  74;  1913,  88;  1914,  77;  1915,  70;  1916,  68.8; 
1917,  77. 

In  1916  there  were  41,163  births  reported  and  2,832  deaths  of  babies 
under  one  year  of  age — an  infant  mortality  rate  of  68.8,  the  lowest  for 
the  six-year  period. 

In  1917  there  were  38,611  births  reported  and  3,005  deaths-^-an  infant 
mortality  rate  of  77. 

The  total  number  of  births  for  1917  was  2,552  less  than  for  1916.  The 
total  number  of  baby  deaths  for  1917  was  173  greater  than  for  1916.f 

The  infant  mortality  rate  proper  does  not  as  yet  include  stillbirths. 
The  number  of  stillbirths  reported  for  1916  was  1,328,  and  for  1917  was 
1,203.  Stillbirths  have  not  shown  any  appreciable  decrease  during  the 
six-year  period,  but  are  rather  on  the  increase.  This  increase  may  be 
relative  rather  than  actual  and  may  be  due  to  improvement  in  birth  and 
death  reporting. 

Of  the  2,832  infants  under  one  year  of  age  who  died  in  1916,  1,462,  or 
slightly  more  than  half,  died  of  congenital  malformation,  premature  birth 
or  congenital  debility.  Of  the  3,005  deaths  of  infants  under  one  year 
who  died  in  1917,  1,394  deaths  are  charged  to  these  causes. 

If  we  add  to  these  figures  1,328  reported  stillbirths  in  1916,  and  1,203 
in  1917,  we  have  as  a  total  for  the  two-year  period  5,397  babies  who  never 
had  a  chance  to  live. 

*  An  exact  method  of  determining  the  infant  mortality  rate  would  require  a  study  of 
babies  born  in  a  given  year  who  died  before  reaching  their  first  birthday,  but  for  prac- 
tical purposes  the  infant  mortality  rate  is  determined  as  above. 

t  Whooping  cough,  measles  and  broncho-pneumonia  were  principally  responsible 
for  this  increase  of  173  deaths.  Broncho-pneumonia,  which  is  a  secondary  infection 
following  measles,  whooping  cough,  scarlet  fever  and  other  children's  diseases,  alone 
was  responsible  for  107  of  the  173  increase. 


120  Kansas  State  Board  of  Health. 

These  figures  do  not  take  into  consideration  the  indefinite  number  of 
infant  lives  lost  through  intrauterine  mortality.  There  is  no  doubt  but 
that  the  number  of  miscarriages  and  abortions,  if  they  were  reported, 
would  equal  if  not  exceed  both  the  stillbirths  and  congenital  mortality. 

This  represents  an  enormous  waste.  In  dollars  and  cents  alone  it 
commands  attention.  Allowing  an  average  minimum  of  $50  expense  for 
each  of  the  5,387  nonproductive  confinements,  it  represents  a  cash  loss 
of  at  least  $269,350.  The  loss  in  cash  is  the  smallest  item.  It  is  not 
possible  to  estimate  the  cost  in  suffering  to  the  mother  and  her  resulting 
ill  health.  Frequently  she  must  even  lose  her  own  life.  This  economic 
and  social  waste  demonstrates  the  importance  of  conserving  the  child 
life  of  the  commonwealth. 


Studies  in  Infant  Mortality.* 

Studies  in  infant  mortality  have  been  undertaken  by  the  National 
Children's  Bureau  in  various  communities  of  the  United  States.  These 
communities  have  varied  greatly — city  and  rural,  industrial  centers,  and 
suburban  residence  districts. 

While  there  is  a  great  difference  in  the  infant  mortality  figures  ob- 
tained between  a  city  and  a  rural  district,  or  between  an  industrial  cen- 
ter and  a  wealthy  surburban  residential  district,  yet  in  all  communities 
certain  factors  in  every  instance  are  found  to  influence  the  infant  mor- 
tality rate. 

Complete  statistical  data  on  the  relation  of  these  factors  to  infant 
mortality  is  not  available  for  Kansas.  The  figures  and  percentages  ob- 
tained by  such  an  investigation  (if  it  were  possible  to  undertake  it)  would 
no  doubt  vary  widely  from  figures  obtained  in  other  parts  of  the  United 
States,  just  as  they  would  vary  widely  in  the  various  communities  of 
Kansas.  However,  the  relation  of  these  factors  to  infant  mortality  would 
not  be  altered. 

For  practical  purposes  the  results  of  these  investigations  conducted 
elsewhere  may  be  taken  as  an  indication  of  the  lines  along  which  public- 
health  work  must  be  directed  if  the  infant  mortality  rate  of  Kansas  is  to 
be  reduced  to  the  minimum. 

FATHERS'  EARNINGS  AND  INFANT  MORTALITY. 

The  infant  mortality  rate  shows  a  marked  and  almost  regular  decline 
as  the  father's  earnings  become  larger.  For  the  group  of  babies  in  which 
the  father's  earnings  are  less  than  $450  per  annum,  the  infant  mortality 
rate  is  242.9  per  1,000  live  births,  while  in  the  next  group,  in  which  the 
father  earns  from  $450  to  $549,  the  rate  is  173.6.  It  rises  very  slightly 
in  the  next  class,  $550  to  $649,  to  174.5,  and  thereafter  drops  steadily 
with  each  advance  in  economic  status.  The  rate,  however,  does  not  fall 
below  100  until  the  father's  earnings  reach  $1,050  or  more.  Babies 
whose  fathers  earn  $1,250  and  over  per  annum  have  a  death  rate  of 
only  58.3. 

*  Statistical  tables  and  data  from  "Studies  in  Infant  Mortality,"  National  Children's 
Bureau. 


Bulletins  Nos.  8  and  9,  August-September,  1918.        121 

HOUSING  AND   INFANT    MORTALITY. 

Low  wages  and  small  income  for  the  family  necessarily  result  in  cheap 
rents  and  poor  housing  conditions.  Bad  housing  and  insanitary  environ- 
ment are  accompanied  by  high  infant  mortality  rates. 

The  homes  of  1,510  babies  visited  had  street  frontage;  129  had  alley 
frontage.  Conditions  in  and  around  alley  and  rear  houses  were  found 
to  be  almost  uniformly  bad,  and  the  infant  mortality  rate  for  babies  in 
such  houses  was  high.  Live-born  babies  in  these  houses  numbered  123,  or 
7.9  percent  of  the  whole  number.  These  babies  died  at  a  rate  of  227.6 
per  1,000  live-births,  while  the  death  .rate  among  babies  in  homes  with 

a  street  frontage  and  a  good  sanitary  environment  was  only  159.4. 

» 

ROOM   CONGESTION   AND   INFANT   MORTALITY. 

Room  congestion  has  a  direct  influence  on  the  infant  mortality  rate. 
Of  the  live-born  babies  included  in  this  investigation  42.5  percent  came 
from  homes  in  which  the  number  of  persons,  exclusive  of  the  baby,  av- 
eraged less  than  1  per  room;  46  percent  in  which  the  average  was  1  but 
less  than  2 ;  6.8  percent  from  homes  in  which  the  average  was  2  but  less 
than  3;  and  1  percent  came  from  homes  in  which  the  average  number 
of  persons  per  room  was  from  3  to  5. 

The  infant  mortality  rate  showed  a  steady  increase  according  to  the 
number  of  persons  per  room.  Where  the  average  number  of  persons  to 
the  room  was  less  than  1,  the  infant  mortality  was  123.3;  where  the 
average  was  more  than  1  but  less  than  2,  the  infant  mortality  rate  was 
177.8;  where  the  average  number  of  persons  to  a  room  was  2  or  more  but 
less  than  3,  the  infant  mortality  rate  was  261.7. 

EMPLOYMENT  OF  MOTHER  DURING  PREGNANCY  AND  INFANT  MORTALITY. 

Work  during  the  year  before  baby's  birth  exerts  a  marked  influence 
on  the  infant  mortality  rate.  Nearly  half  of  the  entire  number  of  babies 
included  in  the  investigation  had  mothers  who  had  engaged  in  gainful 
employment  at  some  time  during  the  year  previous  to  the  baby'g  birth. 
The  occupations  included  504  cases  where  the  work  was  away  from  home, 
427  of  which  consisted  of  employment  in  the  textile  mills  and  47  in  other 
factories. 

Babies  of  mothers  gainfully  employed  during  the  year  preceding  the 
baby's  birth  had  a  mortality '  rate  of  199.2,  whereas  the  rate  for  babies 
of  mothers  who  were  not  so  employed  was  133.9.  The  rate  for  babies  of 
mothers  whose  gainful  work  was  in  the  home  was  149.8;  for  babies 
whose  mothers  worked  away  from  home,  227.5. 

THE   EMPLOYMENT   OF   MOTHERS  DURING  PREGNANCY  AND   STILLBIRTHS. 

The  results  upon  stillbirths  of  a  mother's  work  during  pregnancy  show 
that  mothers  gainfully  employed  have  a  higher  percentage  of  stillbirths 
than  all  mothers,  or  than  those  mothers  not  gainfully  employed.  The 
highest  percentage  occurs  among  mothers  gainfully  employed  away  from 
home,  and  the  lowest  among  those  gainfully  employed  at  home. 


122  Kansas  State  Board  of  Health. 

EMPLOYMENT   OF    MOTHER   DURING   FIRST   YEAR   AFTER   BABY'S   BIRTH 
AND   INFANT   MORTALITY. 

The  employment  of  a  mother  during  the  first  year  after  the  baby's 
birth  exerts  an  influence  on  infant  mortality,  especially  if  complicated  by 
low  wages  and  insufficient  food  and  rest.  A  mother's  intelligence  and 
care  are  also  reflected  in  the  infant  mortality,  although  the  mother's 
ignorance  often  is  a  consequence  of  her  low  wages  and  of  being  compelled 
to  work  at  an  early  age. 

The  employment  of  a  mother  during  the  first  year  of  her  baby's  birth 
directly  interferes  with  breast  feeding,  and  the  lack  of  breast  feeding  in 
turn  raises  the  baby  death  rate.  It  is  impracticable  for  a  mother  to  be 
'gainfully  employed  away  from  home  and  to  breast  feed  a  young  infant. 
A  baby  may  be  bottle  fed  at  six  months  with  comparative  safety.  He  may 
be  bottle  fed  at  three  months  if  extreme  care  is  exercised.  To  put 
a  baby  under  three  months  of  age  on  a  bottle  is  an  exceedingly  hazardous 
undertaking. 

BREAST  FEEDING  AND   INFANT   MORTALITY. 

The  chance  of  survival  for  babies  deprived  of  breast  milk  at  an  early 
age  is  decidedly  less  than  that  for  babies  nursed  for  a  longer  period. 
A  comparison  of  the  breast  fed  and  artificially  fed  babies  from  any  month 
up  to  its  ninth  month  reveals  the  fact  that  the  percentage  which  fails 
to  survive  infancy  is  from  two  to  five  times  higher  among  the  artificially 
fed  babies  than  among  the  exclusively  breast  fed. 

LARGE  FAMILIES  AND   INFANT   MORTALITY. 

There  is  a  higher  mortality  in  the  larger  families.  Combina- 
tions of  four  or  less  pregnancies  are,  for  convenience,  considered  as 
Group  1,  while  the  combinations  of  over  four  are  designated  Group  2. 
The  differences  in  rates  in  the  two  groups  are  notable.  The  infant  mor- 
tality is  much  lower  for  the  first  than  for  the  second  group. 

REPORTABLB    PREGNANCIES  Infant 

FOR  MARRIED  MOTHERS.  mortality 

Group  1 :  rate- 

2  or  less 108 . 5 

3  or  less 124 . 7 

4  or   less..... 119.2 

Group  2 : 

Over    4     171.5 

Over    5     178.8 

Over    6    183.9 

ILLEGITIMACY  AND   INFANT   MORTALITY. 

Of  the  1,551  babies  included  in  this  investigation,  34,  or  2.2  percent, 
were  born  out  of  wedlock.  Nine  of  the  32  illegitimate  babies  born  alive 
died  during  their  first  year. 

MATERNAL    MORTALITY.* 

The  sickness  or  death  of  the  mother  inevitably  lessens  the  chances  of 
the  baby  for  life  and  health.  A  large  proportion  of  the  deaths  of  babies 
occur  in  the  first  days  and  weeks  of  life.  These  early  deaths  can  be 

*  From  "Studies  in  Maternal  Mortality,"  by  the  National  Children's  Bureau. 


Bulletins  Nos.  8  and  9,  August-September,  1918.        123 

prevented  only  through  proper  care  of  the  mother  before  and  at  the 
birth  of  her  baby. 

In  1913  in  this  country  at  least  15,000  women,  it  is  estimated,  died 
from  conditions  caused  by  childbirth;  about  7,000  of  these  died  from 
child-bed  fever,  a  disease  proved  to  be  almost  entirely  preventable,  and 
the  remaining  8,000  from  diseases  now  known  to  be  to  a  great  extent 
preventable  or  curable.  Physicians  and  statisticians  agree  that  these 
figures  are  a  great  underestimate. 

In  1913  childbirth  caused  more  deaths  among  women  15  to  44  years 
old  than  any  disease  except  tuberculosis.  The  death  rates  from  child- 
birth and  from  child-bed  fever  for  the  registration  area  of  this  country 
are  not  falling;  during  the  13  years  from  1900  to  1913  they  have  shown 
no  demonstrable  decrease.  During  that  time  the  typhoid  death  rate 
has  been  cut  in  half,  th«  death  rate  of  tuberculosis  markedly  reduced, 
and  the  death  rate  for  diphtheria  reduced  to  less  than  one-half. 

The  low  standards  at  present  existing  in  this  country  result  chiefly 
from  two  causes:  (1)  General  ignorance  of  the  dangers  connected  with 
childbirth,  and  of  the  need  for  proper  hygiene  and  skilled  care  in  order 
to  prevent  them;  (2)  difficulty  in  the  provision  of  adequate  care  due  to 
special  problems  characteristic  of  this  country.  Such  problems  vary 
greatly  in  city  and  in  country.  In  the  country  the  inaccessibility  of 
skilled  care,  due  to  pioneer  conditions,  is  a  chief  factor. 

Improvement  will  come  only  through  a  general  realization  of  the 
necessity  for  better  care  at  childbirth.  If  women  demand  better  care 
physicians  will  provide  it,  medical  colleges  will  furnish  better  training  in 
obstetrics,  and  communities  will  realize  the  vital  importance  of  com- 
munity measures  to  insure  good  care  for  all  classes  of  women. 

While  the  figures  given  in  this  report  are  a  startling  indication  of 
the  great  number  of  deaths  in  childbirth  occurring  in  various  parts  of 
the  country,  no  estimate  can  be  made  of  the  number  of  mothers  who  sur- 
vive, only  to  suffer  ill  health  which  limits  or  defeats  the  well-being  and 
happiness  of  their  households.  Nor  do  they  include  the  deaths  of  women 
from  kidney,  heart  and  liver  diseases,  which  are  aggravated  by  child 
bearing  to  such  an  extent  that  the  conscientious  physician  warns  against 
pregnancy  in  such  diseases. 


Reduction  of  the  Infant  Mortality  Rate. 

Studies  in  infant  mortality  leave  no  doubt  that  certain  factors  in- 
variably increase  infant  mortality.  Among  them  are  poverty  (low 
wages),  the  employment  of  pregnant  and  nursing  mothers  in  gainful 
occupations,  too  large  families,  illegitimacy,  low  mentality  of  the  parents 
inseparably  associated  with  pauperism  and  illegitimacy,  poor  housing 
and  insanitary  surroundings,  impure  milk  and  bad  food,  and  a  lack  of 
adequate  public  health  protection. 

Ignorance,  disease  and  poverty  sum  up  the  principal  causes  of  infant 
mortality.  A  program  for  the  reduction  of  infant  mortality  to  its  lowest 
irreducible  minimum  must  take  cognizance  of  these  principal  factors. 


124  Kansas  State  Board  of  Health. 

To  control  them  properly  will  require  fundamental  changes  in  our  edu- 
cational, social,  economic  and  political  life. 

But  before  such  changes  may  be  effected  and  for  the  immediate  pres- 
ent certain  methods  are  being  furthered  which  have  proved  their  worth 
in  the  reduction  of  the  infant  mortality  rate  and  in  improving  the  health 
of  all  children.  These  efforts  are  recognized  by  the  boards  of  health  as 
an  important  part  of  their  necessary  program  for  public  health  pro- 
tection. 

PUBLIC   HEALTH   DOCTORS   AND   NURSES. 

"An  epidemic  prevented  is  better  than  two  epidemics  cured"  is  the 
modern  paraphrasing  of  an  old  motto.  This  also  is  the  spirit  of  the  new 
awakening  in  public-health  matters,  which  is  crystallizing  itself  into  a 
demand  on  the  part  of  all  citizens  that  they  and  their  families  be  pro- 
tected from  communicable  diseases  and  that  they  be  accorded  the  very 
best  of  opportunities  for  life,  health  and  happiness. 

The  organized  effort  to  protect  public  health  has  grown  to  such  pro- 
portions as  to  demand  the  entire  time  of  men  and  women  who  are  es- 
pecially qualified  to  serve  in  this  capacity.  Thus  a  new  branch  of  pre- 
ventive medical  activity  has  been  evolved,  requiring  public-health  nurses, 
public-health  physicians,  and  full-time  health  officers. 

The  acquisition  of  a  public-health  nurse  is  the  first  step  in  efficient 
public-health  work.  Especially  is  this  true  in  regard  to  work  for  chil- 
dren. A  nurse  is  necessary  to  the  proper  conduct  of  a  child-hygiene  sta- 
tion, and  her  instruction  is  indispensable  to  the  proper  education  of 
mothers.  Nurses  giving  prenatal  instructions  to  mothers  have  made 
wonderful  records  in  saving  mothers'  and  babies'  lives  and  great  im- 
provement in  the  health  of  both.  Public-health  nurses  are  invaluable  in 
obtaining  thorough  physical  inspection  of  school  children,  assisting  at 
school  clinics,  preventing  outbreaks  of  disease  among  school  children,  and 
for  follow-up  work  in  the  home. 

The  trained  public-health  physician  is  no  less  important  than  the  pub- 
lic-health nurse.  The  custom  has  been  to  employ  as  city  and  county 
health  officers  busy  doctors  who,  in  addition  to  their  regular  practice  and 
for  a  small  yearly  stipend,  have  been  attending  to  the  quarantining  of 
communicable  diseases.  This  quarantining  of  communicable  diseases  is 
many  times  more  expensive  and  less  efficient  than  searching  out  the 
causes  of  epidemic  diseases  and  preventing  them  altogether.  To  do  the 
latter  work  effectively  requires  the  services  of  a  trained  public-health 
physician  devoting  his  whole  time  exclusively  to  that  purpose. 

Proper  public-health  protection  pays. 

PURE   MILK. 

Milk  has  no  substitute  in  the  diet  of  a  child.  Milk  is  the  one  in- 
dispensable food  for  children. 

The  results  of  underfeeding  and  of  the  indiscriminate  use  of  food  sub- 
stitutes in  feeding  children,  as  a  result  of  the  war,  are  being  startlingly 
shown  abroad  and  are  beginning  to  be  evident  in  American  cities.  The 
nourishment  of  its  children  is  plainly  one  of  the  first  duties  of  a  nation. 
And  since  milk  and  milk  products  are  a  vital  necessity  for  children,  for 


Bulletins  Nos.  8  and  9,  August-September,  1918.        125 

nursing  mothers  and  for  the  sick  and  wounded,  the  safeguarding  of  the 
milk  supply  is  a  matter  of  first  concern. 

The  character  of  the  milk  supply  for  cities  in  Kansas  is  controlled  by 
city  ordinance.  A  properly  drawn  ordinance  should  require:  Healthy 
cows;  clean  dairies  and  premises;  clean  operators,  free  from  com- 
municable disease;  facilities  for  hot  water  and  for  sterilizing  all  milk 
utensils;  clean  and  well-drained  and  screened  milk  houses;  and  proper 
provision  for  immediately  cooling  milk  and  keeping  it  cool  until  de- 
livered. To  determine  whether  milk  is  produced  under  such  conditions 
requires  frequent  examination  of  milk  and  plant,  and  laboratory  tests. 

In  cities  where  the  milk  supply  is  not  so  safeguarded  the  parents  of 
small  children  may  well  visit  the  dairy  from  which  they  receive  their 
supply  in  order  to  assure  themselves  that  the  milk  is  cared  for  under  clean 
and  sanitary  conditions  and  cooled  immediately.  Sanitary  standards  for 
the  production  of  safe  milk  and  models  for  city  ordinances  may  be  ob- 
tained free  on  request  to  the  State  Board  of  Health,  Topeka. 

But  a  proper  safeguarding  of  the  milk  from  a  sanitary  standpoint 
does  not  obviate  the  difficulties  arising  from  the  increased  cost  of  feed  and 
labor  necessary  to  produce  milk,  and  the  failure  of  the  average  income  to 
keep  pace  with  the  ever-increasing  high  cost  of  living.  Milk  is  one  of  the 
food  products  which  probably  can  be  handled  best  and  cheapest  by  a 
central  receiving  station  and  pasteurizing  plant,  and  by  a  single  system 
of  distribution.  The  production  of  a  clean,  safe  and  abundant  supply  of 
milk  at  a  price  within  the  reach  of  every  family  is  a  serious  immediate 
problem  facing  many  Kansas  cities. 

PRENATAL   CARE. 

The  first  month  of  life  is  the  period  of  the  highest  infant  mortality 
rate.  In  the  United  States  registration  area  for  1915,  46  percent  of  the 
deaths  under  one  year  of  age  occurred  during  the  first  month,  32  percent 
during  the  first  week,  and  16  percent  during  the  first  day. 

Obviously  this  high  infant  mortality  rate  cannot  be  prevented  by 
measures  instituted  after  the  baby  is  born.  Instead,  this  condition  pre- 
sents an  urgent  necessity  for  preventive  health  measures  before  and 
after  the  baby  is  conceived.  Proper  selection  of  stock  and  right  care 
before  birth  has  long  been  recognized  as  a  cardinal  principle  by  animal 
breeders,  but  it  is  only  within  the  past  few  years  that  the  same  principles 
have  been  generally  recognized  as  applying  to  human  beings. 

Prenatal  care  offers  an  opportunity  to  the  city  and  state  to  direct  its 
health  protection  measures  to  the  "production  plant"  of  its  citizens 
rather  than  to  the  "repair  shops."  It  will  cost  much  less  in  time  and 
money  to  prevent  illness  and  deaths  of  babies  than  it  will  to  pay  for  them 
— and,  besides,  we  would  have  the  babies  left.  A  summary  of  reports  of 
various  experiments  has  abundantly  proved  the  worth  of  prenatal  care. 

Prenatal  care: 

Reduces  the  baby  deaths  during  the  first  year  by  at  least  one- 
half. 

Reduces  the  number  of  stillbirths  one-half. 
Reduces  the  number  of  miscarriages  and  premature  births. 


126  Kansas  State  Board  of  Health. 

Reduces  greatly  the  sickness  and  death  of  the  mothers — puer- 
peral   eclampsia    and    septicemia    (convulsions    and    childbed 

fever)  being  reduced  in  one  experiment  80  percent.* 
Produces  healthier  babies  of  increased  weight. 
Produces  a  greater  number  of  normal  deliveries. 
Increases  the  possibilities  of  the  mother  nursing  her  baby,  thus 

giving  the  baby  a  better  chance  for  its  life. 
Affords  comfort  to  the  baby,  and  peace  to  the  mind  of  the  more 

or  less  sick  and  harrassed  mother. 

Make  possible  a  trained  attendant  at  every  childbirth. 
Method  and  cost.  The  method  of  administering  prenatal  care  is  simple 
and  may  be  undertaken  by  any  thoroughly  trained  nurse.  The  best  results 
are  attained  when  she  is  able  to  watch  her  patient  throughout  the  entire 
period  of  pregnancy.  The  nurse  visits  her  patients  every  week  or  ten  days, 
or  oftener  if  necessary,  keeping  under  close  supervision  the  patients'  diet, 
exercise,  hours  of  work  and  rest,  hygiene  and  health,  including  periodic 
urinalysis.  The  nurse  immediately  refers  to  the  patient's  doctor  any 
unusual  or  untoward  symptoms  which  her  trained  eyes  may  detect. 

Where  the  distances  between  patients  are  not  too  great,  a  nurse  by 
carefully  systematizing  her  work  may  make  from  80  to  100  visits  a 
week.  Averaging  the  difficult  cases,  which  may  require  daily  visits, 
with  those  in  which  the  expectant  mother  is  in  exceptionally  good  health, 
requiring  visits  only  every  second  or  third  week,  the  nurse  can  care  for 
an  average  of  more  than  100  patients. 

The  public  health  nurse's  salary  is  about  $1,000  per  annum,  with  an 
allowance  of  several  hundred  dollars  for  traveling  expense  and  supplies. 
Experiments  in  prenatal  care  have  demonstrated  that  where  the  nurse 
can  be  kept  comfortably  busy  the  expense  averages  about  $3  per*  patient. 
Fewer  patients  would  raise  the  average  cost,  but  in  no  community,  except 
perhaps  the  sparsely  settled  rural  districts  or  where  the  roads  are  im- 
passable, would  the  service  exceed  $5,  a  sum  which  most  expectant 
mothers  would  pay  cheerfully  as  a  wise  investment. 

County  commissioners  and  boards  of  health,  public-health  nursing 
associations,  women's  clubs  and  health  societies  may  profitably  employ 
or  underwrite  the  salary  and  expense  of  a  nurse,  so  that  every  sizable 
community  in  the  state  may  have  at  least  one  prenatal  nurse  to  prevent 
sickness  and  loss  of  life  among  the  babies  and  mothers. 

INFANT  WELFARE   STATIONS. 

The  surest  test  of  a  child's  proper  growth  and  development  is  the 
steady  increase  in  weight,  evidenced  by  regular  weighing.  A  baby 
should  be  weighed  every  week  until  he  is  one  year  old,  and  then  every 
few  weeks  or  month  until  he  is  two  and  one-half  or  three  years  old. 
After  that  age  he  should  be  weighed  at  least  twice  yearly  and  also  given 
a  thorough  inspection  so  that  any  minor  irregularities  of  teeth,  posture, 
nutrition  or  other  organ,  or  function,  may  be  remedied  promptly. 

The  ordinary  spring  baby  scales  are  scarcely  accurate  enough  for 
this  purpose,  especially  as  the  baby  becomes  older  and  heavier.  Scales 

*  Women's  Municipal  League,  Boston. 


Bulletins  Nos.  8  and  9,  August-September,  1918.        127 

with  a  platform  and  beam,  similar  to  the  grocer's  counter  scales,  and 
fitted  with  a  pan  or  basket,  are  much  more  satisfactory.  But  these 
scales  are  comparatively  expensive,  and  not  all  homes  are  equipped  with 
them. 

To  overcome  this  difficulty  a  group  of  mothers  may  request  the 
county  health  authorities  to  provide  proper  scales  and  to  place  them 
conveniently  at  the  county  seat.  If  the  city  or  county  employs  a  public- 
health  nurse,  she  may  meet  with  the  mothers  one  afternoon  a  week, 
assist  them  with  the  weighing,  inspect  the  babies,  and  refer  those 
who  need  medical  attention  to  their  doctors.  The  nurse  may  also  advise 
the  mothers  about  the  care  and  feeding  of  the  children  and  about  the 
health  of  themselves  and  their  families. 

Location.  By  experience  it  has  been  found  that  stations  in  rest  rooms 
of  dry-goods  stores  are  very  well  attended.  The  mother,  incidental  to 
her  shopping,  can  have  her  baby  weighed  and  inspected  by  the  nurse, 
thus  saving  her  a  special  trip  for  the  purpose.  A  public  rest  room  also 
offers  a  good  headquarters  for  a  welfare  station.  Many  country  women 
visit  these  rooms.  Incidentally  they  may  become  interested  in  having 
their  children  examined  when  otherwise  they  would  not  go  to  a  station' 
in  another  location. 

The  public  schoolhouse,  especially  in  those  districts  in  which  the 
infant  mortality  rate  is  high,  is  another  good  location  for  a  child-hygiene 
or  infant-welfare  station.  In  most  school  buildings  a  room  may  be  found 
which  can  be  used  for  this  purpose  one-half  or  one  day  each  week  and 
in  which  the  records  and  necessary  equipment  may  be  kept.  This  plan 
has  the  approval  of  the  state  department  of  education.  A  room  in  the 
city  building  or  other  public  building  may  serve.  But  the  farther  the 
mother  is  compelled  to  go  in  order  to  reach  the  station  the  more  difficult 
it  is  for  her  and  the  less  likely  she  is  to  attend. 

Equipment.  .The  furnishings  of  a  station  should  be  of  the  simplest 
and  the  plainest  kind.  Each  should  be  equipped  with  a  good  pair  of 
scales  and  suitable  pan  or  basket  for  weighing  the  babies,  a  measuring 
rod  and  tape  line,  a  table,  sufficient  chairs  and  suitable  records,  and 
always  with  paper  towels  and  sufficient  linen  for  sanitary  standards.  If 
funds  and  space  permit,  a  table  and  utensils  for  modification  of  milk, 
blackboard,  exhibit  of  layette,  and  a  model  nursery  may  be  provided. 

BETTER  BABY  EXAMINATIONS  OR  CHILDREN'S  HEALTH  CONFERENCE. 

The  infant-welfare  station  makes  possible  the  periodic  examination  of 
large  numbers  of  babies.  Where  there  are  no  such  stations  established 
these  examinations  may  be  conducted  singly  and  privately,  one  baby  at  a 
time,  in  the  doctor's  office,  or  they  may  be  conducted  in  groups  publicly  as 
Baby  Day  or  Better  Babies  Week. 

Examination  cards,  instructions  and  literature  necessary  to  the  con- 
duct of  a  baby  examination  are  furnished  free  by  the  Kansas  State  Board 
of  Health,  Division  of  Child  Hygiene. 

BIRTH   REGISTRATION   TEST. 

Births  are  reportable  by  law,  and  there  is  a  heavy  penalty  for  failing 
or  refusing  to  report  them.  However,  birth  reports  are  sometimes  over- 
looked or  forgotten.  It  is  obvious  that  if  all  the  deaths  of  a  community 


128  Kansas  State  Board  of  Health. 

are  reported  and  that  only  part  of  the  births  are  reported,  that  commun- 
ity is  being  charged  with  a  higher  infant  mortality  rate  than  it  merits. 

Correct  birth  reports  and  birth  certificates  are  becoming  increasingly 
important.  A  certificate  of  birth  may  be  required  to  prove  descent,  to 
prove  inheritance  of  property,  to  obtain  a  pension,  to  enter  school,  to  ob- 
tain employment,  for  civil  service,  to  establish  ability  to  make  contracts, 
to  enter  the  professions,  to  join  the  army  or  navy,  for  court  purposes, 
to  marry,  and  for  other  purposes. 

A  careful  checking  of  all  the  births  in  a  community  is  not  only  a  val- 
uable service  to  the  community  itself,  but  it  may  be  of  inestimable  service 
to  the  citizens  born  within  its  limits. 

EDUCATIONAL  LITERATURE — KANSAS   MOTHERS'  BOOK. 

While  a  careful  birth  registration  test  will  reduce  the  infant  mortality 
rate,  it  will  not  reduce  the  actual  number  of  baby  deaths.  This  can  be 
done  by  improving  the  health  conditions  of  a  community,  and  especially 
by  reaching  the  mothers  with  educational  literature  and  personal  instruc- 
tion. 

The  Kansas  Mothers'  Book,  issued  by  the  Kansas  State  Board  of 
Health,  Division  of  Child  Hygiene,  contains  practical  information  re- 
garding child-bearing  and  child-rearing  in  simple  and  concise  language. 
It  discusses  also  the  public-health  phases  of  child  hygiene  and  welfare, 
so  that  the  mother  may  understand  and  cooperate  with  the  various 
agencies  of  the  state  to  which  she  may  appeal  for  service. 

MOTHERS  CONFIDENTIAL  REGISTRY  FOR  PRENATAL  LETTERS. 

Important  factors  influencing  a  child's  health  and  life  begin  before  he 
is  born.  To  be  born  well  is  a  considerable  part  of  the  battle.  When 
conception  occurs  the  "gates  of  gifts"  to  the  child  are  closed.  The  par- 
ents gave  their  child  what  they  were,  not  what  they  would  like  to  be. 
From  this  time  on  they  can  only  conserve  the  life  and  provide  the  best 
possible  environment  for  their  child's  development,  both  before  and  after 
birth. 

Expectant  mothers  are  urged  to  enroll  in  the  Mothers'  Confidential 
Registry,  Division  of  Child  Hygiene,  Topeka,  giving  name  and  address 
and  the  date  of  the  expected  confinement.  They  will  receive,  without 
charge,  a  series  of  nine  prenatal  letters  and  the  phamplet  "Prenatal 
Care,"  issued  by  the  National  Children's  Bureau. 

When  the  birth  of  a  baby  is  reported  a  blank  certificate  and  a  Kansas 
Mothers'  Book  will  be  sent,  provided  the  mother  has  not  already  received 
one.  Expectant  mothers  and  mothers  of  children  may  also  write  the 
Division  of  Child  Hygiene  regarding  the  many  perplexing  questions  as- 
sociated with  child-bearing  and  child-rearing. 

CARE    AND    TREATMENT    OF    DEFECTIVE,    CRIPPLED    OR    DEPENDENT    CHILDREN. 

It  is  not  alone  the  children  of  parents  in  poor  circumstances  who  need 
physical  or  medical  attention.  A  considerable  percentage  of  all  children 
need  dental,  medical,  hygienic  or  corrective  treatment.  If  not  remedied 
these  apparently  simple  physical  ailments  of  childhood  sometimes  seriously 
interfere  with  a  child's  growth  and  development,  and  his  health  and 


Bulletins  Nos.  8  and  9,  August-September,  1918.        129 

efficiency  in  later  years.     The  results  of  the  draft  examination  in  the 
United  States  abundantly  attest  this  fact. 

It  is  hoped  that  the  significance  of  the  neglect  of  physical  ailments  of 
children  may  be  brought  to  the  attention  of  every  parent  or  guardian  of 
a  child.  By  reporting  such  children  to  the  State  Board  of  Health, 
Division  of  Child  Hygiene,  an  effort  will  be  made  to  advise  parents  or 
guardians  as  to  the  appropriate  kind  and  suitable  source  of  treatment. 

COMMUNICABLE   DISEASE   CONTROL, 

The  common  diseases  of  childhood — measles,  whooping  cough,  and  so 
forth — which  are  erroneously  thought  to  be  comparatively  harmless,  are 
responsible  for  the  deaths  of  thousands  of  children  annually.  The 
younger  the  child  contracts*  one  of  these  diseases,  the  greater  the  chances 
that  he  will  die,  for  the  younger  the  child,  always  the  higher  the  mor- 
tality rate. 

While  these  diseases  do  not  always  kill,  they  are  likely  to  cripple  and 
maim.  They  are  responsible  for  much  of  the  deafness,  poor  eyesight  and 
illhealth  of  adults.  Thus  the  conservation  of  child  life  and  the  health 
of  the  adult  depend  to  a  considerable  degree  upon  the  control  of  these 
diseases. 

Every  epidemic  has  its  starting  point  in  some  unrecognized  commu- 
nicable disease,  or  from  the  delayed  report  and  the  consequent  delay  of 
quarantine  or  other  public-health  protection  measure.  The  efficiency  of  at 
health  department  depends  upon  its  means  and  ability  to  isolate  promptly 
and  to  prevent  the  spread  of  contagion. 

Physicians  are  required  to  report  all  communicable  diseases  to  the 
health  officer.  But  many  cases  occur  where  no  physician  is  in  attendance. 
In  such  cases  the  householder  is  charged  with  the  responsibility  of  report- 
ing. If  he  fails  to  do  so  his  neighbors  ought  to  report  the  cases  in  jus- 
tice to  the  health  of  their  own  families. 

Public  health  and  welfare  demand  that  every  person,  to  a  certain  ex- 
tent, shall  be  a  deputy  health  officer  and  sanitary  inspector.  The  matter 
of  proper  public-health  protection  is  a  matter  of  good  citizenship  and  an 
exemplification  of  the  Golden  Rule. 

CHILD  CONSERVATION  HOUSE-TO-HOUSE  CANVASS. 

There  is  no  other  method  of  putting  literature  into  the  hands  of  every 
mother  and  expectant  mother  and  of  checking  all  births  and  epidemic 
diseases  except  by  the  house-to-house  canvass.  Clubs,  Sunday-school  or- 
ganizations, senior  high-school  students,  colleges  and  other  groups  in- 
terested in  public  health  and  child  hygiene  are  invited  to  undertake  this 
survey  in  their  home  precincts.  This  canvass  is  made  by  voting  precincts, 
and  wherever  possible,  under  the  direction  of  a  county  chairman,  woman's 
committee,  Council  of  Defense.  Blanks  for  this  canvass,  press  material 
and  all  necessary  literature  are  furnished  by  the  State  Board  of  Health, 
Division  of  Child  Hygiene. 


2— Health— 4194 


SCHOOL  HYGIENE.* 


The  Cost  of  Neglect. 

A  PROBLEM   IN   SCHOOL  ARITHMETIC. 

Enrollment  in  grade  schools,  total  for  year  19161 398,288 

Expenditures  for  grade  schools,  total  for  year  19161 $13,358,750.86 

Average  cost  of  school  year  per  pupil  enrolled $33 .  54 

Pupils  failing  to  make  a  grade  each  year,  average,  city  and  country2.  ...  14.3% 

Annual  number  of  pupils  failing  to  make  a  grade 56,955 

Annual  loss  caused  by  pupils  repeating  grades $1,910,270  .  70 

A  saving  of  this  amount  of  money  will  not  be  represented  by  less 
money  being  spent  on  the  schools,  but  by  obtaining  value  received  for 
money  now  being  wasted.  This  first  cost  of  retardation,  the  loss  of  school 
money  alone  if  it  might  be  so  utilized,  would  provide: 

One  school  nurse  (salaries  and  expenses)  for  each  thousand  grade 
pupils  and  a  similar  amount  for  school  physicians  and  school  clinics. 

One  teacher  of.  physical  education  for  each  thousand  grade  pupils,  and 
similar  sum  for  playground  and  gymnasium  equipment. 

One  special  teacher  for  ungraded  classes  for  each  thousand  grade 
pupils,  and  for  the  necessary  trained  mental  examiners. 

Those  special  teachers  would  enable  normal  children  to  keep  up  with 
their  grades  and  assist  the  supernormal  children  to  go  ahead  as  fast  as 
their  ability  would  permit.  They  would  also  relieve  the  classroom  of  the 
drag  of  the  subnormal  and  feebleminded  children  and  give  them  the  rudi- 
ments of  training  which,  supplemented  by  special  institutional  train- 
ing,3 would  make  them  more  or  less  self-supporting  and  self-respecting 
citizens. 

*  The  subject  of  School  Hygiene  will  be  taken  up  in  a  later  issue  of  the  bulletin  of 
the  Kansas  State  Board  of  Health. 

1.  From  the  twentieth  biennial  report  of  the  state  superintendent  of  public  instruction 
of  Kansas  for  the  year  ending  June  30,  1916. 

2.  Total  retardation — pupils  one  year  or  more  behind  the  proper  grade  for  their  age — 
jn  cities,  30.6  percent;  in  country,  39  percent.     Investigation  conducted  by  School  of  Edu- 
cation, University  of  Kansas,  school  year  ending  June,  1916. 

3.  This  estimated  cost  of  preventing  retardation  does  not  include  the  cost   of   caring 
4  or  the  2  percent  of  school  children  who  are  recognized  as  feeble-minded.     Such  care  can- 
not properly  be  charged  to  the  public  school  funds.     Funds  for  the  care  of  feeble-minded 
in  this  state  are  appropriated  to  the  departments  of  charities  and  corrections  administered 
U>y  the  Board  of  Administration. 


(130) 


Bulletins  Nos.  8  and  9,  August-September,  1918.        131 


Physical  Examination  of  School  Children. 

The  schools  are  spending  millions  in  educating  or  trying  to  educate 
children  who  are  kept  back  by  ill  health,  when  the  expenditure  of  thou- 
sands in  a  judicious  health  program  would  produce  an  extraordinary 
saving  of  ill  health  and  an  increase  in  economy  and  efficiency.  A  dollar 
spent  in  wise,  constructive  effort  to  conserve  a  child's  health  and  general 
welfare  will  be  more  fruitful  for  the  child  and  for  the  general  good  than 
a  hundred  times  that  sum  delayed  for  twenty  years.  The  principle  of 
thrift  in  education  finds  its  first  and  most  vital  application  in  the  con- 
servation and  improvement  of  the  health  of  the  children. 

Every  school  child  should  have  a  health  examination  once  a  year. 
More  frequent  examinations  should  be  provided  for  individual  pupils  who 
need  special  attention.  All  health  examinations  and  attention  in  rural 
and  in  city  schools  should  be  under  the  supervision  of  regularly  appointed 
school  physicians  thoroughly  trained  for  their  work.  There  should  be 
for  every  child  a  health  as  well  as  a  scholarship  record  which  accom- 
panies him  through  his  public  school  career.  This  should  be  a  part  of  the 
records  of  the  school  which  the  child  is  attending. 

The  simpler  tests  of  vision  and  hearing  can  be  made  by  the  teacher 
as  well  as  the  routine  morning  health  inspection.  Capable  teachers  can 
easily  learn  simple  methods  of  routine  physical  examination.  The  more 
detailed  examination  is  the  work  of  the  physician.  But  where  even 
the  simplest  of  physical  examinations  may  not  be  undertaken,  every 
teacher  may  take  the  height  and  weight  of  each  child.  This  height  and 
weight  and  their  relation  to  each  other  and  to  the  child's  age  are  a  rough 
index  to  his  physical  condition. 

•»  Standard  height  and  weight  cards,  also  blanks  for  complete  physical 
examination  of  school  children,  will  be  sent  free  on  application  to  the 
State  Board  of  Health,  Division  of  Child  Hygiene. 


Height  and  Weight  Tests  of  School  Children.* 

An  adult  may  be  underfed  for  a  long  period  without  serious  results, 
but  a  child  if  undernourished  will  never  become  as  strong  and  capable  an 
adult  as  he  might  have  been.  The  detection  of  malnutrition  requires  no 
expert  medical  knowledge.  The  weight  of  the  child  and  his  rate  of  gain 
tells  the  story. 

Malnutrition  exists  among  school  children  to  an  almost  incredible  de- 
gree. A  recent  survey  in  New  York  shows  that  of  a  million  school 
children  in  that  city,  approximately  150,000  are  stunted  in  their  growth, 
retarded  from  one  to  three  years  in  height  and  weight.  In  other  parts  of 
the  country  malnutrition  prevails  probably  to  even  a  greater  degree,  as 
New  York  has  shown  more  than  ordinary  interest  in  the  welfare  of  her 
school  children  and  has  made  relatively  large  appropriations  for  the  pro- 
tection of  the  health  of  her  children.  This  degree  of  malnutrition  (proba- 

*  Adapted  from  publications  of  Child  Health  Organization,  289  Fourth  avenue,  New 
York  City.  Free  literature  sent  on  request. 


132  Kansas  State  Board  of  Health. 

bly  one-third  of  all  school  children)  extended  into  adult  life  would  cause 
every  one  of  these  individuals  to  be  rejected  from  the  army  as  physically 
unfit. 

Malnutrition  to  this  degree  exists  because  there  has  been  no  effective 
physical  inspection  of  school  children,  which  would  have  located  it  and 
steps  therefore  would  have  been  taken  to  correct  it.  Undernourished  chil- 
dren may  look  well  when  dressed,  thus  they  are  considered  to  be  well. 
But  a  careful  inquiry  into  their  condition  would  reveal  that  they  are  pale 
or  even  anemic,  that  they  are  listless  and  inattentive  to  their  studies,  and 
that  they  are  easily  fatigued  both  physically  and  mentally.  When  such 
children  fall  behind  in  their  studies  they  are  considered  lazy,  and  pres- 
sure at  home  and  school  is  increased.  Thus  a  vicious  circle  is  established 
which  further  increases  the  difficulty.  These  children  in  later  life  often 
become  physical  and  nervous  wrecks. 

The  first  step  in  combating  malnutrition  among  school  children  is  to 
locate  individual  cases.  This  requires  no  expert  medical  knowledge.  A 
pair  of  scales,  a  tape  measure  and  a  chart  of  heights  and  weights  are  all 
that  is  necessary.  If  the  school  does  not  possess  a  pair  of  scales  or  can- 
not buy  them,  the  children  will  readily  go  to  the  grocers  or  butchers  to  be 
weighed  regularly  for  the  fun  of  it,  especially  if  a  game  is  made  of  the 
proceeding  and  a  little  rivalry  or  competition  is  arranged  for  them.  The 
children  will  also  enter  heartily  into  the  idea  of  bringing  themselves  up  to 
normal  weight  and  condition  as  a  part  of  their  patriotic  duty  as  good 
citizens. 

Having  located  the  undernourishment,  the  next  thing  to  do  is  to 
discover  the  causes.  A  sympathetic  physician  will  be  of  inestimable  serv- 
ice at  this  point.  In  almost  every  school  district  one  or  more  doctors 
may  be  found  Who  will  donate  their  services  for  the  necessary  physical 
examination.  This  examination  will  show  from  three  to  nine  defects  in 
every  undernourished  child,  and  often  as  many  in  those  of  normal  weight. 
The  defects  of  most  serious  concern  to  the  child's  condition  are  those  that 
interfere  with  respiration,  enlarged  or  diseased  tonsils  or  adenoids  and 
faulty  posture.  Other  common  defects  which  affect  the  child's  health  and 
school  efficiency  are  bad  teeth,  faulty  vision,  bad  hearing  or  discharging 
ears,  skin  diseases,  and  results  of  children's  diseases.  It  is  most  im- 
portant that  the  child  and  the  parents  understand  these  defects  and  the 
urgent  necessity  for  their  treatment. 

The  third  step  is  to  check  up  the  food  habits  of  the  children  and  pro- 
vide them  with  a  proper  diet  for  their  age  and  condition.  Besides  taking 
too  little  food,  many  of  these  children  have  bad  food  habits — eating  too 
fast,  going  without  breakfast,  drinking  tea  or  coffee,  eating  candy  be- 
tween meals,  or  refusing  cereals  and  milk.  The  child's  habits  of  sleep, 
study,  play  and  exercise  should  also  receive  attention,  as  all  are  con- 
cerned in  his  health  and  growth. 

Such  physical  inspection  and  care  would  eliminate  malnutrition  among 
school  children  in  a  short  time.  It  would  also  effect  a  tremendous  saving 
of  school  money  which  is  now  wasted  in  trying  to  educate  children  who 
are,  to  all  intents  and  purposes,  sick  children. 


CHILD  WARDS  OF  THE  STATE. 


Dependent  Children. 

The  child  may  be  taken  out  of  home  life  and  become  dependent  upon 
the  state  for  a  variety  of  reasons.  In  every  instance  the  state  becomes 
responsible  for  the  providing  or  the  failing  to  provide  the  personal  care 
and  educational  facilities  which  will  make  that  child  an  independent  citi- 
zen, a  happy  human  being  and  a  worthy  social  unit.  In  cases  where  it 
is  not  possible  to  make  a  safe  member  of  society  out  of  the  child  he  is 
entitled  to  be  given  into  humane  and  scientific  custodial  care.  This  is 
essential  both  for  the  sake  of  the  child  and  for  the  best  interest  of  society. 

In  spite  of  a  general  social  quickening  to  the  rights  of  the  dependent 
child,  many  states,  including  Kansas,  still  remain  curiously  apathetic 
and  inert  with  reference  to  his  rights.  While  no  one  could  be  found 
who  would  wish  for  this  child  to  receive  anything  but  fair  treatment,  there 
are  few  willing  to  actively  espouse  his  cause  and  see  that  he  gets  a  square 
deal.  As  it  is,  the  state  seems  to  be  satisfied  with  the  cold  charity  of  a 
private  institution,  or  by  grudging  appropriations  to  state  institutions 
keep  only  soul  and  body  together,  and  provide  the  modicum  of  education 
stipulated  in  the  constitution. 

There  are  at  present  time  some  1,000  dependent  children  living  in  23 
institutions  designed  for  their  care.*  The  State  Orphanage  cares  for  less 
than  200  of  these;  the  rest  are  to  be  found  scattered  about  in  orphans' 
homes  of  the  widest  range  of  purpose,  equipment  and  efficiency.  These 
homes  are  incorporated  under  the  laws  of  the  state,  and  thirteen  of 
them  receive  some  state  aid.  In  addition  to  these  incorporated  institu- 
tions there  are  an  unknown  number  of  nonincorporated,  private  board- 
ing houses  and  maternity  homes  which  exploit  their  victims  instead  of 
soliciting  funds.  Thus  they  evade  the  letter  of  the  law  which  regulates 
the  conduct  of  only  those  institutions  soliciting  funds  for  charitable  pur- 
poses. Worst  of  all,  several  counties  in  the  state  of  Kansas  still  consign 
children  to  the  poorhouse. 


What  is  a  Good  Children's  Home? 

The  state  of  Kansas,  which  permits  dependent  .children,  orphaned  or 
half -orphaned,  to  be  cared  for  by  a  variety  of  children's  institutions, 
homes  and  home-finding  societies,  each  of  which  is  a  separate  corpora- 
tion, se1  f -perpetuating,  virtually  self-directing  and  practically  without 
supervision,  is  beginning  to  question,  "What  is  a  good  children's  home?" 

The  average  citizen  .probably  could  answer  the  question,  "What  is  a 
good  children's  home?"  only  in  the  most  general  terms — that  the  children 
be  well  fed;  that  they  be  clothed  and  kept  clean;  that  they  be  kindly 

*  Sixth  Biennial  Report  of  Board  of  Control  of  State  Charitable  Institutions. 

(133) 


134  Kansas  State  Board  of  Health. 

treated,  and  that  a  doctor  be  called  when  they  are  sick.  And  an  insti- 
tution apparently  answering  such  requirements  no  doubt  would  be  re- 
ported upon  as  a  first-class  institution  by  a  visiting  lay  committee. 
Where  such  institutions  have  been  visited  and  so  reported  by  lay  com- 
mittees, a  trained  investigator  following  has  uncovered  some  unexpected 
details. 

That  the  children  be  well  fed:  The  expert  found  extremes  of  under- 
weight and  overweight,  indicating  that  these  children  were  not  well  fed; 
that  the  same  food  was  being  served  to  the  entire  group  of  children 
ranging  in  age  from  2  to  16  years;  that  there  were  no  prepared  menus 
or  other  provision  for  such  variety  of  diet  as  would  give  the  children 
nutritious  and  at  the  same  time  the  most  palatable  food. 

That  the  children  be  clothed  and  kept  clean:  The  trained  investigator 
found  that  the  children  were  kept  clean  because  they  were  not  per- 
mitted to  play  for  fear  of  soiling  their  clothes. 

That  the  children  be  kindly  treated:  The  trained  investigator  found 
that  the  children  were  not  whipped  but  they  were  deprived  of  necessary 
articles  of  food  for  petty  offenses,  made  to  kneel  on  cold  stone  floors  or 
shut  in  dark  closets  for  misconduct  growing  out  of  nervous  disorders, 
when  they  needed  instead  expert  medical  attention. 

That  a  doctor  be  called  when  they  are  sick:  The  expert  found  that 
more  than  half  of  these  children  in  such  institutions  required  medical  or 
dental  care,  and  that  such  care  as  was  being  given  sick  children  was 
indifferent,  careless  and  incompetent. 

The  absence  of  sickness  does  not  indicate  proper  nor  sufficient  medical 
attention  for  a  children's  institution.  Some  children's  homes  pride  them- 
selves on  the  statement  that  "No  doctor  has  been  inside  our  home  for  a 
year  or  more."  This  is  not  a  matter  for  congratulation.  Instead,  it  is 
a  serious  comment  upon  the  lack  of  understanding  of  the  service  a  doctor 
should  perform  for  children.  Prevention  is  the  goal  of  modern  medical 
science,  and  "no  sickness"  does  not  necessarily  indicate  health. 

It  is  not  safe  for  any  nonmedical  superintendent  of  a  children's 
institution  to  assume  that  the  children  are  well  so  long  as  he  does  not 
see  that  they  are  ill.  Accurate  knowledge  of  a  child's  physical  condi- 
tion is  essential  to  determine  what  is  necessary  to  his  perfect  health  and 
welfare.  This  knowledge  can  be  obtained  only  by  thorough  and  periodic 
physical  examination  by  a  competent  physician,  and  the  services  of  ex- 
perts in  consultation  or  treatment  when  necessary. 

Obviously  then  these  general  terms  that  the  children  be  well  fed, 
clothed,  kept  clean,  kindly  treated,  and  a  doctor  called  when  they  are 
sick  do  not  adequately  characterize  what  properly  might  be  called  a 
good  children's  home.  These  must  be  followed  by  specifications  as  to 
what  is  the  right  sort  of  feeding,  what  is  proper  cleanliness,  what  is 
meant  by  being  kindly  treated,  and  what  is  sufficient  health  protection. 

In  addition  to  these  purely  physical  aspects  of  a  good  children's  home, 
what  about  its  management  and  more  especially  its  ideals?  What  atti- 
tude does  the  institution  take  concerning  the  children?  Are  the  children 
themselves  the  real  ends  developed  and  conserved,  or  are  they  the  mere 
pawns  of  some  other  purpose  of  the  institution? 

What  provision  is  made  for  the  higher   educational  and  vocational 


Bulletins  Nos.  8  and*9,  August-September,  1918.        135 

equipment  for  life  of  these  children?  What  are  the  aims  of  the  insti- 
tution as  to  the  attainment  of  its  wards?  Does  it  regard  each  child  as 
an  individual,  especially  as  to  the  kind  of  work  required  of  him? 

And  what  is  most  important  of  all,  is  the  institution  getting  anywhere 
in  its  service  to  the  children?  Or  does  it  fill  in  a  few  years  of  their 
young  lives  in  a  sort  of  indifferent  way,  beginning  with  no  fixed  pro- 
gram and  ending  with  no  definite  results? 

In  an  effort  to  answer  the  perplexing  question  as  to  what  is  a  good 
children's  home,  various  boards  of  health,  charities  and  welfare  have 
investigated  hundreds  of  these  homes.  They  have  enumerated  all  the 
factors  entering  into  a  children's  home,  its  plant,  administration  and 
ideals,  and  have  endeavored  to  fix  a  minimum  standard  of  excellence  for 
each  factor.  It  was  found  comparatively  easy  to  enumerate  factors  and 
standards  of  excellence  so  far  as  the  physical  plant  of  the  institution  is 
concerned.  It  is  vastly  more  difficult  and  very  much  more  important  to 
enumerate  them  so  far  as  the  management  and  ideals  are  concerned. 

Obviously  any  arbitrary  standard  of  excellence  for  children's  homes 
has  had  to  undergo  numerous  modifications  in  the  light  of  practice  and 
experience.  No  doubt,  as  methods  in  the  care  and  management  of  chil- 
dren progress,  these  standards  will  undergo  still  further  changes.  How- 
ever, in  the  light  of  our  present  knowledge  and  experience,  a  home  for 
children  should  be  able  to  pass  a  creditable  inspection  according  to  such 
standards  already  outlined.* 

How  Institutions  are  Rated.  For  convenience  in  rating,  institutions 
ordinarily  fall  roughly  into  one  of  four  classes — A,  B,  C,  and  D. 

Class  A  institutions  are  those  which  measure  up  to  the  general  re- 
quirements. These  institutions  are  adequately  equipped,  well  managed, 
effectively  planned  and  efficiently  conducted.  They  are  giving  scientific 
care  to  their  children  as  well  as  a  happy  home  life,  and  are  meeting  the 
needs  of  their  community  to  the  extent  of  their  capacity. 

Class  B  institutions  are  those  which  are  lacking  in  some  respects,  but 
which  are  making  a  strong  effort  to  attain  to  the  general  requirements. 
These  institutions  are  not  always  properly  equipped.  In  their  manage- 
ment they  are  prone  to  substitute  good  intentions  for  scientific  knowledge. 
And  while  their  ideals  are  high  enough,  they  have  rather  hazy  and  in- 
definite or  altogether  mistaken  ideas  as  to  how  to  put  them  into  prac- 
tice or  bring  them  about. 

Behind  such  an  institution  one  generally  finds  a  genuinely  self-sacri- 
ficing board,  working  not  for  glory  or  for  profits  but  solely  for  the  wel- 
fare of  the  children.  This  sort  of  institution  offers  something  tangible  to 
work  upon.  With  scientific  direction  as  to  hygienic  arrangements,  bal- 
anced diets,  medical  treatment  of  children,  child  placing  and  other  prob- 
lems, and  with  proper  official  recognition  and  support,  such  homes  may 
readily  be  brought  into  class  A. 

Class  C  institutions  are  those  which  have  serious  defects  as  to  plant, 
administration  and  ideals.  The  equipment  of  these  institutions  is  poor, 
the  management  lax  or  grossly  incompetent,  the  ideals  low,  and  the  pur- 
poses for  which  a  children's  home  should  be  maintained  lost  sight  of  in 
the  pursuit  of  money,  religious  proselyting  or  fanaticism,  or  merely  the 

*  Child  Caring  Institutions,  Department  of  Public  Charities,  New  York  City. 


136  Kansas  State  Board  of  Health. 

endeavor  to  appear  philanthropic.  While  in  a  few  instances  these  in- 
stitutions may  be  cited  as  doing  good,  yet  on  the  whole  they  are  doing 
actual  harm  in  that  they  fall  so  far  short  of  any  satisfactory  program  of 
child  care  or  of  equipping  their  children  in  any  measure  for  a  normal 
home  life.  These  institutions  have  been  allowed  to  exist  for  years  on 
the  same  dead  level  of  inefficiency,  because  of  a  general  lack  of  under- 
standing as  to  what  a  children's  institution  should  be,  also  because  of 
lack  of  interest  or  courage  on  the  part  of  the  community  and  the  state  to 
demand  their  improvement. 

Class  D  institutions  are  those  showing  an  absence  of  all  progressive 
child-caring  standards  in  plant,  administration  and  ideals.  Among  these 
are  the  wholly  useless,  the  disreputable  and  the  illicit. 

According  to  this  method  of  rating,  there  is  not  a  single  home  for 
children  in  Kansas  entitled  to  a  rating  of  class  A,  although  there  are 
several  that  with  a  little  assistance  and  direction  may  attain  this  rating. 
There  are  many  class  B  institutions,  and  as  many  or  more  perhaps  in 
class  C  than  in  class  B ;  there  are  several  in  class  D. 

Class  B  institutions  need  official  recognition  and  constructive  super- 
vision. 

Class  C  institutions  need  the  same  perhaps  in  greater  detail.  If  they 
fail  to  take  cognizance  of  official  direction,  they  should  be  compelled  to 
improve  or  be  closed. 

Class  D  institutions  should  be  discontinued  without  parley  or  tempo- 
rizing and  the  helpless  children  removed  to  more  favorable  environment. 


Inspection  of  Children's  Institutions. 

The  wide  diversity  of  conditions  obtaining  among  the  children's  insti- 
tutions in  Kansas  may  be  judged  from  the  following  extracts  from  con- 
fidential reports  on  file  with  the  State  Board  of  Health  and  the  State 
Board  of  Administration.  These  reports  were  made  by  various  compe- 
tent persons — members  of  the  Boards  of  Health  and  Administration  and 
their  staffs,  by  agents  of  the  Federal  Children's  Bureau,  by  college  in- 
structors, and  by  others  equipped  for  special  phases  of  this  sort  of  in- 
spection. 

CHILDREN'S  HOMES. 

Rescue  Mission  and  Orphan  Asylum.  This  institution  harbored  55  in- 
mates, about  half  of  them  babies  under  three  years  of  age.  The  adults 
represented  various  stages  of  social  maladjustments.  A  tabulation  of 
the  infant  deaths  in  this  institution  showed  that  out  of  a  total  of  26 
deaths  for  the  given  period,  6  were  from  inanition  and  10  from  entero- 
colitis,  which  are  terms  for  improper  feeding. 

Twenty  or  more  toddlers  were  found  in  a  so-called  day  nursery,  which 
was  reached  by  passing  through  a  filthy  kitchen  and  unlocking  a  door. 
All  of  them  were  whining  or  fretting — some  were  coughing.  Around 
three  sides  of  this  room  was  a  shelf  about  a  foot  wide  and  covered  with 
oil  cloth.  The  small  chairs  were  pushed  in  front  of  it,  and  from  the  shelf 
th}  children  were  eating.  There  was  absolutely  nothing  in  the  room  be- 
side this  shelf,  the  chairs  and  the  children.  The  little  ones  were  dirty  and 
unkept.  There  was  no  older  person  with  them.  Both  doors  were  locked 


Bulletins  Nos.  8  and  9,  August-September,  1918.        137 

and  windows  tightly  closed  and  covered  with  dust  and  cobwebs.  On 
asking  to  see  the  play  yard,  a  back  door  was  opened  and  a  chicken  pen 
divided  from  barn  by  high  board  fence  and  gate  was  revealed.  The  barn 
with  a  manure  pile  thrown  out  of  its  window  was  within  thirty  feet  of 
this  place,  while  investigation  showed  the  front  yard  was  large  and  set 
with  shrubbery  and  flower  beds. 

Five  or  six  babies  were  found  in  the  nursery  upstairs,  several  of  them 
exhibiting  extreme  degrees  of  malnutrition.  The  odor  in  this  nursery 
was  so  vile  that  it  was  almost  impossible  to  stay  in  the  room.  A  number 
of  young  children  in  the  cribs  were  in  wretched  condition.  One  was  suck- 
ing a  mixture  of  peach  tree  leaves,  supposedly  for  teething  troubles. 

The  one  small  bathroom  in  the  house  was  equipped  with  one  tub,  one 
seat,  an  old  tin  wash  basin  and  a  common  towel.  The  matron  told  us 
these  were  for  the  use  of  the  entire  establishment.  A  few  wash  bowls 
and  pitchers  were  seen  on  the  third  floor,  which  apparently  constituted  a 
rude  hospital  for  the  care  of  women  in  confinement. 

This  home  is  not  properly  equipped  to  take  care  of  children;  it  is  in- 
s?nitary  and  dirty;  the  children  are  not  kept  clean  nor  properly  fed;  the 
death  rate  is  higher  than  it  ought  to  be;  it  is  not  a  fit  place  for  young 
children  so  long  as  adults  of  all  ages  and  stages  of  moral  and  social  de- 
generacy are  being  brought  there  constantly;  and  the  managemeiit  is 
bringing  children  from  other  states  contrary  to  law,  such  children  being 
likely  to  become  public  charges  in  Kansas. 

Children's  Home  No.  1.  The  children  in  this  institution  were  found 
playing  happily.  They  were  entirely  free  from  restraint  and  called  the 
matron  "mother."  They  were  clean  and  in  very  good  condition  con- 
sidering the  lack  of  equipment.  The  building  is  old,  without  running 
water,  toilet  or  bathroom  facilities,  and  entirely  unsuited  for  the  purpose. 
There  were  more  than  20  children,  with  sleeping  quarters  for  only  half 
that  number.  The  children  were  sleeping  four  or  five  in  one  bed. 

Children's  Home  No.  2.  The  equipment  of  this  home  is  pitifully  in- 
sufficient. The  house  is  old  and  in  such  a  bad  state  of  repair  that  it  needs 
to  be  replaced  by  a  new  one.  Considering  its  age  and  condition  and  the 
difficulty  of  keeping  such  a  home  clean,  the  house  was  in  exceedingly  good 
order.  The  chi!4ren  were  happy,  free  from  restraint,  and  gave  every  evi- 
dence of  being  kindly  treated  and  well  cared  for  to  the  best  ability  of  the 
management. 

The  home  needs  to  provide  individual  towels  and  toothbrushes  for  the 
children's  bathroom.  The  teeth  of  all  the  children  should  be  examined 
and  necessary  dental  work  undertaken.  Many  of  the  teeth  were  in  bad 
condition.  The  health  of  these  children  would  be  greatly  improved  by  a 
thorough  physical  examination  and  corrective  treatment.  A  mental 
test  should  also  be  given  each  child  when  admitted.  It  was  apparent 
that  several  of  these  children  were  feeble-minded  or  suffering  such  other 
mental  defects  as  would  make  them  unsuitable  for  adoption  or  indenture 
purposes.  Such  mental  and  physical  examination  should  be  extended 
also  to  the  employees,  several  of  whom  did  not  come  up  to  proper 
health  and  ability  standards.  One  woman  in  particular  was  waiting  on 
the  children  while  suffering  with  a  bad  cough,  obviously  of  a  tubercular 
nature. 


138  Kansas  State  Board  of  Health. 

Children's  Home  No.  3.  This  institution  was  housed  in  an  old  two- 
story  frame  building  which  was  as  clean  as  good  housekeeping  can  make 
it.  The  sanitary  arrangements  were  bad  and  the  building  was  totally 
inadequate  for  the  purpose  for  which  it  was  being  used.  The  steam- 
heating  plant  was  out  of  order.  A  few  of  the  rooms  were  being  heated 
by  gas  stoves. 

The  children,  about  a  dozen  of  them,  including  three  of  the  superinten- 
dent's own,  were  found  in  a  dark  semibasement,  which  was  used  also  as 
a  kitchen  and  dining  room.  To  reach  this  room  the  children  must 
descend  a  very  steep,  dark  and  unsafe  stairway  and  pass  through  a  room 
which  is  used  as  a  laundry.  It  was  neither  a  safe  nor  proper  place  for 
them,  and  instructions  were  given  to  the  superintendent  to  utilize  a 
large  room  on  the  first  floor,  which  needs  only  heat  and  some  equipment 
to  make  a  first-class  play  room. 

This  home  has  been  warned  repeatedly  by  the  former  Board  of 
Control  to  put  its  heating  plant  in  order  and  to  take  the  children  out  of 
the  dark  semibasement.  Apparently  it  needs  more  than  warning. 

Children's  Home  No.  4.  This  institution  contains  about  a  dozen 
children,  with  adequate  quarters  for  twice  that  number.  The  place  was 
immaculately  clean — perhaps  too  clean  for  comfort.  The  best  room  in 
the  house — a  large  south  room  which  would  be  ideal  for  a  children's  play 
room — has  been  reserved  for  the  exclusive  use  of  the  board  meetings. 

The  day  the  inspection  was  made  the  children  were  in  the  yard,  locked 
out  of  the  house  while  the  kitchen  floor  was  being  cleaned.  There  was 
no  play  room  in  this  house,  no  library,  and  very  few  games  or  toys.  The 
dining  room  was  cheerless,  and  no  tablecloths  or  napkins  were  used.  The 
food  was  good,  but  the  service  was  so  unattractive  and  the  dining  room 
so  cheerless  as  not  to  be  conducive  to  good  manners  or  good  digestion. 

There  was  no  tooth  powder  nor  toothbrushes  for  the  children.  Prac- 
tically every  child  in  this  institution  needs  some  medical  or  dental  treat- 
ment. At  the  time  of  the  inspection  there  were  two  feeble-minded  girls 
of  child-bearing  age  in  the  home.  Both  of  them  should  be  sent  to  Win- 
field  for  permanent  custodial  care. 

Children's  Home  No.  5.  This  children's  home  was  housed  in  a  beauti- 
fully appointed  building  and  in  most  respects  was  in  excellent  order.  The 
children  were  absolutely  free  from  restraint  and  the  institution  would 
pass  as  high  class.  The  present  dormitories  were  crowded,  making  it 
difficult  to  obtain  a  sufficient  supply  of  fresh  air.  The  windows  in  the 
boys'  play  room  were  closed  and  the  fastenings 'were  locked.  This  room 
was  crowded  also  and  had  a  decidedly  bad  odor. 

The  medical  attention,  while  of  a  high  order  and  better  than  the  aver- 
age children's  home,  still  is  not  adequate.  One  physician  in  general  local 
practice  devoting  his  part-time  services  to  more  than  seventy  children 
cannot  give  them  medical  attention  in  accordance  with  modern  standards. 
It  is  suggested  that  instead  of  one  practicing  physician,  a  staff  of  chil- 
dren's specialists  which  are  available  for  this  institution  be  organized, 
so  that  these  children  may  have  the  best  treatment  obtainable.  With  a 
few  minor  changes  this  institution  could  come  into  class  A. 


Bulletins  Nos.  8  and  9,  August-September,  1918.        139 

MATERNITY   HOMES. 

Maternity  Home  No.  1.  This  institution  was  found  to  be  in  beautiful 
condition.  The  home  was  clean  and  attractive  and  the  girls  gave  every 
evidence  of  being  well  cared  for.  At  the  time  the  inspection  was  made 
there  was  found  an  imbecile  who  had  just  given  birth  to  a  baby — her 
third.  She  had  given  birth  to  twins  preyiously.  Yet  this  girl  cannot 
be  sent  to  a  proper  institution  without  the  consent  of  her  parent  or  guar- 
dian. Unfortunately  parents  and  guardians  rarely,  if  ever,  recognize 
the  need  for  proper  care  for  this  sort  of  a  girl.* 

Maternity  Home  No.  2.  This  home  -was  housed  in  an  old  two-story 
frame  dwelling  in  a  bad  state  of  repair.  The  inmates  consisted  of  sev- 
eral aged  indigents,  six  children  from  eleven  to  sixteen  years  of  age, 
and  one  maternity  case.  The  maternity  case  was  a  colored  imbecile, 
thirty  years  of  age,  of  a  very  low  order  of  intelligence,  almost  an  idiot, 
who  had  given  birth  to  a  baby  a  month  previous.  A  mother  of  such1  a 
low  grade  of  intelligence  cannot  in  any  sense  be  held  responsible  for  her 
conduct,  nor  is  such  a  baby  fit  for  adoption. 

Application  papers  were  sent  to  her  county  to  have  the  mother  and 
baby  sent  to  Winfield  for  permanent  custodial  care,  but  owing  to  the 
peculiarities  of  the  feeble-minded  law  in  Kansas  such  a  girl  cannot  be  sent 
without  the  consent  of  her  guardian  or  parent.  The  girl  presumably  has 
been  returned  to  her  home.  The  usual  history  of  such  cases  is  that  they 
return  in  a  few  years  with  another  baby. 

Maternity  Home  No.  3.  This  maternity  home  is  also  being  used  as 
a  temporary  detention  home  for  children  and  adults.  The  home  is  wretch- 
edly poor  and  in  exceedingly  bad  hygienic  condition.  There  is  no  medical 
attention,  as  the  matron  herself  is  a  midwife  and  attends  the  girls  in 
confinment. 

At  the  time  of  the  inspection  there  was  in  the  home  a  feeble-minded 
pregnant  woman  (possibly  insane),  twenty  years  old,  with  her  two  de- 
fective children.  The  oldest  child,  two  years  old,  could  not  stand  alone. 
The  baby  was  seven  or  eight  months  old,  and  the  woman  was  expecting 
the  third  child  in  a  few  months  more.  The  husband  at  the  time  was 
before  the  court  on  nonsupport  and  cruelty  charges.  This  man  may  be 
punished  by  being  fined  or  sent  to  jail.  There  is  -no  law  which  provides 
permanent  custodial  care  for  such  a  man  and  woman  and  their  children. 
Yet  it  is  very  obvious  that  if  these  two  are  allowed  to  continue  in  their 
present  way  they  will  in  time  produce  a  large  family  of  feeble-minded 
and  defective  children. 

Maternity  Home  No.  4-  This  institution  was  housed  in  a  three-story 
ramshackle  old  fire  trap.  The  sanitary  arrangements  were  very  bad 
and  the  home  was  exceedingly  dirty.  There  was  no  heat  provided  in  any 
of  the  girls'  rooms.  The  confinment  room  was  heated  by  an  open  stove. 
The  ward  room  where  the  patients  convalesce  was  heated  by  a  soft-coal 
laundry  stove.  This  home  is  so  far  below  the  minimum  standards  of 
hygiene  and  decency  that  it  ought  either  to  be  compelled  to  improve  and 
clean  up  at  once,  or  it  should  be  closed  without  any  further  temporizing, 
and  the  girls  removed  to  better  surroundings. 

*  Since  sent  to  Winfield. 


140  Kansas  State  Board  of  Health. 

PRIVATE  INSTITUTIONS  FOR  CHILDREN,   NONINCORPORATED  AND 
NONCHARITABLE. 

If  present  methods  of  inspection  and  regulation  are  lax  concerning 
incorporated  institutions,  they  are  hopeless  in  so  far  as  the  nonincor- 
porated  institutions  are  concerned. 

Not  one  board  in  the  state ^of  Kansas,  nor  the  combined  authority  of 
all,  can  reach  the  very  worst  offenders — the  private  boarding  home  or 
institution  which  is  nonincorporated  and  which  does  not  solicit  funds. 

Under  the  present  laws  of  Kansas  any  sort  of  person  at  any  time  or 
place  may  open  any  sort  of  home  or  hospital  for  children  or  expectant 
mothers,  and  conduct  it  in  any  sort  of  way,  without  even  the  knowledge 
of  any  authority  of  the  state,  much  less  any  kind  of  supervision  or  con- 
trol. 

The  following  extract  from  a  Kansas  City  paper  is  a  glaring  example 
of  what  has  already  happened  in  Kansas.  The  Charter  Board  has  no 
record  of  this  home,  and  neither  the  Board  of  Administration  nor  the 
Board  of  Health  knew  that  such  a  home  was  in  operation  until  the  story 
was  uncovered  by  newspaper  reporters. 

Maternity  Home.  "Amid  the  most  miserable  surroundings,  in  a  house 
in  which  there  was  no  light,  no  heat  except  a  small  oil  stove  in  one  room, 
and  no  water,  a  nameless  baby  boy  came  into  the  world  at last  Fri- 
day night.  The  only  attendant  to  the  unfortunate  eighteen-year-old 
mother  was  another  girl  whose  baby  had  been  born  five  days  before  and 
taken  from  her.  She  had  never  seen  it.  The  telephone  in  the  house  had 
not  been  connected,  and  help  could  not  be  summoned  by  that  means. 
There  was  no  food  in  the  house.  Alone  with  the  young  mother,  in  abso- 
lute darkness  save  for  the  red  glare  on  the  floor  from  the  oil  stove,  she 
had  been  carried  into  the  house  but  a  few  hours  before.  The  other  girl 
dressed  herself  as  best  she  could  and  in  the  chilling  wind  made  her  way 
to  the  house  of  a  neighbor.  '  There  she  told  the  story  of  the  unfortunate 
young  mother  in  the  big,  cold,  dark  house  across  the  street. 

"These  girls  had  come  to  the  so-called  maternity  home  which  had  been 
advertised  in  Kansas  City  papers.  They  were  charged  $10  a  week  and 
$25  when  the  baby  was  born.  In  spite  of  the  fact  that  they  had  paid  for 
care  and  medical  attention,  the  unfortunate  girls  were  given  no  medical 
attention,  not  even  a  nurse,  were  given  only  cold  food — ham,  crackers 
and  oranges — and  were  not  provided  with  hot  water.  The  doctor  who 
had  been  conducting  this  maternity  home  has  a  long  and  unenviable  court 
record."* 

A  Private  Boarding  Home  for  Children.  This  home  boards  children, 
charging  from  two  to  five  dollars  a  week.  Living  in  a  six-room  cottage 
were  the  matron  and  three  adult  members  of  her  family,  one  boarding 
mother,  and  ten  children.  The  five  adults  and  ten  children  were  pro- 
vided with  three  double  beds  and  one  tick  on  the  floor.  Two  of  these 
children  were  girls  about  eleven  and  thirteen,  and  one  boy  was  about 
thirteen.  The  sanitary  and  hygienic  conditions  of  this  home  were  in- 
describable. 

*  This  doctor  was  brought  into  the  county  court,  but  as  the  girls  did  not  appear  against 
him  he  was  acquitted.  His  court  re9ord  was  submitted  to  the  Kansas  State  Board  of 
Medical  Examiners,  who  have  auhority  to  revoke  the  license,  but  so  far  no  action  has  been 
taken. 


Bulletins  Nos.  8  and  9,  August-September,  1918.        141 

The  only  recourse  under  the  present  law  is  to  obtain  a  court  order  for 
removal  of  these  children.  There  is  nothing  to  prevent  others  from  being 
put  there  as  fast  as  the  court  takes  them  out. 

Day  Nursery  and  Boarding  Home.  The  home  was  fairly  well  ar- 
ranged, but  was  very  untidy.  As  too  many  children  were  taken,  it  was 
too  crowded.  The  matron  and  one  feeble-minded  woman  were  trying  to 
feed  and  care  for  twenty-five  or  thirty  children.  The  nursery  beds  were 
not  supplied  with  sheets  and  clean  bedding.  The  beds  and  mattresses 
were  in  bad  condition. 

SUMMARY. 

Instances  of  exploitation  and  tragic  lack  of  proper  care  of  the  de- 
pendent children  of  Kansas  could  be  repeated  in  endless  sequence,  but 
enough  has  been  said  to  indicate  that  there  is  something  radically  wrong 
with  the  present  method  of  dealing  with  dependent  children.  More  than 
a  million  dollars  is  invested  in  the  state  of  Kansas  in  orphanages  for  the 
care  of  these  children.  These  places  spend  in  the  aggregate  between  two 
and  three  hundred  thousand  dollars  every  year,  and  still  these  unfor- 
tunates receive  nothing  but  bare  subsistence.  The  method  is  wasteful 
and  inefficient,  and  what  is  worse,  robs  defenseless  children  of  their 
natural  birthright. 

A  state  orphan  asylum  in  this  day  and  age  is  an  anachronism.  It 
does  n't  belong.  It  exists  only  as  a  monument  to  indifference,  ignorance 
and  neglect.  The  present  State  Orphans'  Home  could  with  advantage  be 
transformed  into  a  clearing-house  and  child-study  laboratory — the  only 
legitimate  use  for  a  congregate  home.  This  should  be  used  as  a  receiv- 
ing station  for  every  unfortunate  child  in  the  state.  Here  the  child  should 
have  complete  physical  and  mental  examination  and  treatment  and  should 
be  brought  up  to  physical  par  with  the  greatest  possible  rapidity.  His 
heredity  and  temperament  should  be  studied,  and  when  it  becomes  clear  as 
to  what  is  the  proper  place  for  him  he  should  be  fitted  into  that  place.  If 
he  is  a  fit  subject  for  adoption  or  care  in  a  normal  home,  he  should  be 
given  into  the  care  of  a  specially  trained  agent  to  be  fitted  into  a  home, 
and  carefully  watched  until  he  reaches  maturity  and  relieves  the  state  of 
further  responsibility. 

If  he  is  found  to  be  unfit  for  life  in  a  home  by  reason  of  physical  or 
hereditary  limitations,  he  should  be  placed  in  the  custody  of  some  institu- 
tion especially  equipped  to  care  for  his  particular  condition.  This  method 
would  automatically  empty  and  dispense  with  the  small,  inefficient  local 
orphanages. 

The  state  of  Kansas  should  make  it  impossible  for  any  individual  or 
group  of  individuals  to  receive  children  or  pregnant  women  without  a 
proper  license,  regular  inspection,  and  the  same  amenability  to  the  law  as 
incorporated  hospitals,  hotels,  eating  houses  and  other  public  accommoda- 
tions. 

It  should  forbid  the  detention  of  children  in  pcorhouses,  jails  or  other 
places  where  feeble-minded,  insane  or  criminals  are  kept,  or  other  persons 
of  a  character  undesirable  as  associates  of  innocent  childhood. 

It  should  arrange  for  the  creation  of  a  responsible  body  of  specialists, 
or  the  powers  of  the  Division  of  Child  Hygiene  should  be  increased,  to 


142  Kansas  State  Board  of  Health. 

whom  should  be  entrusted  the  working  out  and  administration  of  a  plan 
for  the  care  of  all  child  wards  of  the  state,  including  foundlings. 


Child  Placing. 

The  normal  child  belongs  in  a  home,  not  in  an  institution.  Every  insti- 
tution in  Kansas  receiving  children  has  the  right  to  indenture  or  adopt 
children  into  homes,  but  not  a  single  institution  has  adequate  and  compe- 
tent machinery  for  placing  children  or  for  supervising  them  after  adop- 
tion. 

The  biennial  report  of  the  State  Orphans'  Home  for  1914-'16  states 
that  the  Home  at  that  time  had  out  under  active  indenture  more  than  500 
children.  It  has  one  agent  to  place  and  supervise  these  children.  The 
maximum  number  which  one  agent  can  place  and  keep  under  supervision 
with  anything  like  adequate  attention  is  fifty.  With  a  small  district,  good 
facilities  for  transportation  and  the  cumulative  advantage  of  acquaint- 
ance with  the  territory,  this  number  may  under  favorable  conditions  be 
increased  to  100.  The  advice  of  expert  investigators,  however,  is  that  the 
number  be  limited  to  50  children  per  agent.  The  statement  made  in  this 
report  that  the  one  state  agent  of  the  State  Orphanage  cannot  possibly 
supervise  500  children  should  receive  attention  and  active  consideration.* 

There  are  no  reports  available  as  to  the  number  of  children  who  have 
been  indentured  previously  by  other  organizations  caring  for  children, 
with  the  exception  of  the  State  Orphan's  Home  and  the  Kansas  Children's 
Home-finding  Society.  If  the  State  Orphans'  Home,  caring  for  less  than 
one-fifth  of  the  dependent  children  of  the  state,  has  500  out  at  one  time 
under  indenture,  it  is  probable  that  there  are  from  3,000  to  4,000  children 
scattered  about  in  homes  of  the  state. 

It  is  inhumane  to  take  a  defenseless  child  out  into  the  state  and  lose 
him,  for  that  is  what  it  amounts  to  when  the  agency  which  places  the 
child  fails  to  keep  in  touch  with  him.  Families  have  even  moved  out  of 
the  state  taking  indentured  children  with  them,  and  left  no  trace.  It 
would  be  difficult,  if  not  impossible,  to  even  locate  all  the  children  of  pres- 
ent minor  age  who  have  been  thrown  upon  the  tender  mercies  of  families 
and  forgotten. 

One  children's  home-finding  society  has  about  1,000  children  under 
supervision  in  homes.  These  are  under  the  active  supervision  of  six  dis- 
trict agents.  These  children  remained  in  the  receiving  home  for  an  av- 
erage of  only  twenty  days  each.  Children  in  need  of  surgery  or  medical 
attention  were  attended  to  before  they  were  sent  into  the  homes.  This 
organization  finds  no  difficulty  in  finding  homes  for  children.  The  super- 
intendent states  that  there  are  always  from  one  to  two  hundred  appli- 

*  "Our  experience  in  placing  of  children  has  completely  confirmed  in  our  mind  that 
90  percent  of  those  who  take  our  children  into  their  homes  do  so  for  commercial  reasons 
and  not  because  of  any  real  love  for  the  child  or  desire  to  benefit  his  condition.  It  is  for 
what  they  can  get  out  of  him  in  dollars  and  cents  rather  than  for  what  they  can  see  in 
him  as  a  future  citizen  of  the  commonwealth.  .  .  .  Those  in  need  of  cheap  help  take 
the  children  out  in  the  spring  and  keep  them  during  the  busy  season,  and  return  them 
when  the  work  is  over  and  they  must  be  at  the  expense  and  trouble  of  sending  them  to 
school  and  otherwise  provide  for  their  training." — From  Report  of  Superintendent  of 
State  Orphans'  Home  for  biennial  period  1914-'16.  This  statement  is  sufficient  evidence 
of  the  charge  that  the  State  Orphans'  Home  is  not  competent  to  investigate  the  homes 
into  which  it  sends  the  cMld  wards  of  the  state,  nor  equipped  to  supervise  them. 


Bulletins  Nos.  8  and  9,  August-September,  1918.        143 

cations  for  children  on  file.  No  papers  are  made  out  until  a  child  has 
been  on  probation  in  the  home  under  the  supervision  of  an  agent  for 
ninety  days.  If  at  the  end  of  this  time  both  family  and  child  seem  happy 
and  suited  to  each  other,  papers  of  indenture  or  adoption  are  signed. 
Children  are  often  moved  before  the  expiration  of  the  probation  period, 
but  seldom  afterward. 

This  organization  at  one  time  offered  to  accept  from  the  state  and  place 
in  suitable  homes  and  supervise  all  the  children  suitable  for  placement 
which  should  be  given  to  them  for  this  purpose,  and  to  do  it  at  a  total  cost 
to  the  state  of  $50  per  child.  It  cost  during  the  biennial  period  of  1914-'16 
an  average  of  $239.34  yearly  per  capita  for  the  support  of  the  children 
in  the  State  Orphans'  Home.  Certain  of  these  children  properly  belong 
in  the  School  for  the  Feeble-minded.  The  majority  of  them,  however, 
are  suitable  or  can  be  made  suitable  for  placement  and  adoption.  There 
is  no  question  but  that  it  is  far  cheaper  in  the  long  run  to  place  and 
supervise  than  to  support  them. 

Granting  that  there  are  1,000  children  in  residence  in  orphanages  and 
4,000  more  scattered  over  the  state,  or  an  estimated  total  of  5,000  chil- 
dren whom  we  will  assume  to  be  suitable  for  normal  home  life,  it  would 
require  a  force  of  fifty  paid  agents  to  place'  and  systematically  visit  all 
these  children,  and  the  total  expense  to  the  state  would  approximate 
$150,000.  Allowing  a  maximum  salary  of  $1,800  and  maximum  travel- 
ing expenses  of  $1,200 — a  total  of  $3,000  per  year  for  each  agent — with 
an  average  of  100  children  assigned  to  each  for  placement  and  super- 
vision, the  average  per  capita  expense  per  child  would  approximate  $30. 

The  reports  from  the  private  orphanages  are  too  imperfect  to  fur- 
nish data  as  to  per  capita  cost  and  attendance.*  Taking  the  per  capita 
cost  at  the  State  Orphans'  Home  as  a  basis  (in  all  probability  some 
homes  spend  less  and  some  more),  it  costs  the  public  of  the  state  approxi- 
mately $240,000  per  year  to  support  this  thousand  children  in  residence  in 
institutions,  or  a  sum  sufficient  to  place  and  adequately  supervise  all  the 
5,000  dependent  children  of  the  state  and  keep  a  record  of  them  until 
maturity,  and  have  a  balance  of  some  $90,000  per  year  to  devote  to  the 
maintenance  of  an  adequate*  clearing  house,  detention  home  and  child 
laboratory. 

It  is  not  good  business,  it  is  not  humane,  to  continue  the  present  ar- 
chaic, ineffective,  outgrown  method.  The  war  is  raising  thetvalue  of  the 
individual  citizen  and  making  Ufe  very  hard  for  the  unprotected.  Both 
sentiment  and  common  sense  demand  speedy  action. 

*  Tabulations  were  made  of  the  reports  for  the  fiscal  year  ending  June  30,  1916,  of 
twenty-two  institutions  legally  authorized  by  the  state  to  receive  and  dispose  at  will  of  de- 
pendent children,  and  required  by  law  to  render  yearly  reports  covering  specified  points. 
Two  children's  homes  and  five  maternity  homes  made  no  report  whatever  as  to  the  number 
of  children  handled  or  their  disposition.  Nine  homes  reported  receiving  a  total  of  208 
more  children  than  they  accounted  for,  while  five  other  institutions  reported  the  disposal 
of  a  total  of  47  more  children  than  they  had  received! 

The  institutions  (including  the  State  Orphans'  Home)  reporting  on  this  point  reported 
themselves  as  having  cared  for  a  total  of  1,803  children  during  the  year.  They  reported 
908  as  remaining  in  residence  at  the  end  of  the  year  covered  by  the  report.  A  minimum 
estimate  of  the  children  cared  for  by  the  remaining  seven  institutions  makes  it  appear 
certain  that  at  least  a  thousand  children  were  at  that  time  in  residence  in  these  twenty- 
two  homes.  It  is  safe  to  assume  that  this  figure  remains  fairly  stationary. 

The  average  daily  number  of  inmates  does  not  appear  on  these  reports,  with  the  excep- 
tion of  the  State  Orphans'  Home.  The  financial  reports  are  not  accurately  made,  only  six 
showing  debit  and  credit  statements  which  balance.  It  is  therefore  impossible  to  figure 
the  per  capita  cost  of  the  support  of  the  inmates  of  private  orphanages. 


144  Kansas  State  Board  of  Health. 


Children  in  Kansas  Poorhouses. 

,  The  county  poorhouse,  as  it  is  usually  administered,  is  a  close  relative 
of  the  medieval  almshouse  of  deservedly  odious  repute.  Yet  within  the 
past  year  in  the  state  of  Kansas  twenty-four  children  in  six  counties  have 
been  incarcerated  with  the  veritable  "scum"  of  feeble-minded,  hopelessly 
insane  and  social  derelicts  who  people  these  institutions. 

In  response  to  inquiry  as  to  why  these  children  were  harbored  in  the 
poorhouses,  several  reasons  were  given: 

Most  often,  the  young  child  remains  in  the  custody  of  a  feeble-minded 
or  derelict  mother,  who  goes  and  comes.  Sometimes  she  goes  and  comes 
until  she  has  two  or  three  children  for  the  obliging  county  officials  to 
take  care  of. 

A  temporarily  dependent  mother  and  children  are  cared  for  in  the 
poorhouse  and  the  children  sent  to  school.  This  is  not  in  accordance  with 
the  intent  of  the  mother's  pension  law. 

The  probate  judge  commits  juvenile  offenders  or  truants  to  the  alms- 
house  awaiting  their  trial.  In  one  county  a  colored  girl  of  eleven  and  a 
white  girl  of  about  the  same  age  were  kept  in  the  county  house  all  sum- 
mer awaiting  the  action  of  court. 

Dependent  children  are  carelessly  committed  to  the  county  house  be- 
cause there  is  no  orphanage  near  and  it  seems  easier  to  keep  them  at  the 
expense  of  the  county  in  the  county  home  than  to  send  them  to  the  state 
orphanage.  One  boy  of  thirteen  was  sent  to  the  poor  farm  when  both 
his  parents  were  sent  to  the  penitentiary  and  has  remained  there  for 
three  years,  and  is  now  drawing  wages  as  a  helper. 

Every  one  of  these  classes  of  children  belongs  elsewhere.  No  county 
house  or  other  place  stigmatized  by  the  term  "pauper"  is  a  proper  place 
for  any  child.  No  child  is  or  can  become  a  pauper,  because  the  state 
which  permitted  him  to  be  born  within  its  jurisdiction  owes  him  support 
and  education  commensurate  with  good  standards  of  citizenship,  regard- 
less of  adverse  accidents  of  circumstance. 


Defective  Children. 

There  are  five  special  classes  of  defective  children  who  should  be 
separated  from  normal  dependent  children  and  also  from  normal  homes. 
These  are  the  feeble-minded,  the  blind,  the  deaf  and  dumb,  the  epileptic, 
and  the  crippled.  This  separation  is  necessary,  both  for  the  sake  of 
obtaining  for  the  atypical  child  the  specialized  care  his  condition  indicates, 
and  also  for  the  sake  of  relieving  the  home  and  school  in  certain  instances 
of  his  undesirable  influence. 

Kansas  has  established  the  following  institutions  for  the  care  of  these 
children : 

Population. 

State  School  for  the  Feeble-minded,  Winfield   663 

State  School  for  the  Blind,  Kansas  City 104 

State  School  for  the  Deaf,  Olathe    240 

Colony  for  Epileptics,  Parsons  (both  adults  and  children),  chil- 
dren, approximately  125 

1,132 


Bulletins  Nos.  8  and  9,  August-September,  1918.        145 

Besides  these  four  classes,  the  state  provides  medical  and  surgical  care 
for  indigent  children  at  the  State  University  Medical  School  at  Rosedale. 

While  the  exceptional  child  must  have  specialized  care  such  as  can  sel- 
dom be  given  him  in  any  home,  every  precaution  should  be  taken  to 
make  him  feel  as  normal  as  possible.  A  special  study  should  be  made 
in  each  of  these  groups  of  the  psychology  of  "set-apartness"  and  its 
reaction  upon  the  effective  physical  and  mental  life  of  the  child. 

Along  with  orphanage,  the  special  institution  needs  to  emerge  from 
the  custodial  to  the  research  conception  of  its  function  and  duty.  No 
institution  for  defective  children  should  be  permitted  to  lapse  into  mere 
custody  of  the  person  of  the  limited  child. 

FEEBLE-MINDED. 

There  are  at  present  663  feeble-minded  persons  in  residence  in  the 
state  institution  at  Winfield.  These  are  chiefly  idiots  and  low-grade 
feeble-minded,  whose  mentality  is  of  such  a  caliber  that  they  do  not  re- 
spond to  educational  effort. 

The  vital  problem  to  the  state  is  not  the  detection  and  care  of  the  low- 
grade  idiot  who  can  harm  no  one,  but  rather  the  individual  who  becomes 
arrested  at  the  mental  age  of  7,  8  or  10  years,  but  whose  animal  appetites 
and  passions  go  on  to  full  maturity.  These  are  the  individuals  who 
furnish  a  very  important  percentage  of  the  inmates  of  penitentiaries, 
houses  of  prostitution,  jails,  poorhouses,  houses  of  correction  and  re- 
formatories. These  individuals  propagate  their  kind  freely  and  un- 
reservedly. The  consequence  is  that  society  replenishes  itself  much  more 
lavishly  from  the  bottom  than  from  the  top. 

The  crux  of -the  whole  matter  lies  in  getting  the  mentally  retarded 
child  young  enough  to  give  him  appropriate  vocational  training  and 
chance  for  self-development.  //  it  be  found  that  he  can  never  arrive 
at  a  mental  age  of  sufficient  maturity  for  social  safety,  he  should  be  seg- 
regated in  time  to  keep  him  from  becoming  a  social  menace. 

A  complex  machinery  is  necessary  in  order  to  accomplish  this  effect- 
ively: . 

1.  The  location  of  mentally  retarded  children  in  the  schools.     This 
can  be  done  within  wide  limits  by  the  untrained  teacher.    It  can  be  done 
effectively  only  by  the  trained  psychiatrist. 

2.  The  establishment  of  a  suitable  number  of  ungraded  classes  under 
specially  trained  teachers,  in  order  that  these  children  may  be  taught  the 
things  that  they  have  the  capacity  to  learn,  and  especially  that  they  may 
have  vocational  training  to  fit  them  to  become  self-supporting.     When  it 
becomes  apparent  that  they  cannot  be  made  competent  to  lead  a  safe  and 
independent  existence,  they  should  be  taken  out  of  the  public  school  and 
sent  to  the  state  school. 

3.  A  state  training  school  and  psychopathic  hospital  for  the  study  of 
the  problems  of  feeble-mindedness,  for  research,  and  for  the  education  of 
children  who  do  not  have  access  to  special  teaching  in  the  public  school 
or  who  present  special  problems  in  mental  abnormality. 

This  training  school  and  psychopathic  hospital  might  be  built  in  con- 
nection with  the  present  custodial  institution  at  Winfield.  This  would  mass 
3— Health— 4194 


146  Kansas  State  Board  of  Health. 

the  problem  of  mental  variation  which  would  be  an  advantage  as  far  as 
research  activities  are  concerned  and  it  would  economize  administrative 
machinery.  Other  phases  of  the  problem  of  feeble-mindedness  are  dis- 
cussed in  the  legal  section  of  this  bulletin. 

THE   BLIND   AND   DEAF. 

The  vocational  competency  in  after  life  of  both  the  blind  and  the  deaf 
depends  so  directly  upon  the  quality  of  specialized  teaching  they  receive, 
that  it  is  necessary  that  they  be  well  taught  in  order  to  save  them  from 
lifelong  dependency.  Many  soldiers  will  be  coming  back  blind  and  deaf 
and  in  urgent  need  of  specialized  vocational  training.  It  is  a  mistake 
not  to  keep  these  schools  at  their  highest  efficiency  on  the  eve  of  a  greater 
need  than  ever  for  highly  specialized  teaching  machinery. 

The  state  of  Kansas,  in  common  with  many  others,  has  deemed  it  the 
part  of  economy  to  get  the  work  of  its  institutions  done  as  cheaply  as 
possible.  This  is  a  false  economy  for  any  institution,  but  more  especially 
in  the  case  of  the  blind,  because  they  are  less  able  to  assist  with  the  work 
of  the  school  plant  and  require  more  personal  assistance. 

A  certain  percentage  of  blindness  and  of  deafness  is  inheritable.  It  is 
known  that  there  is  a  group  of  men  and  women  in  southeastern  Kansas 
affected  with  inheritable  forms  of  these  defects  (some  of  them  former 
students  of  the  state  schools)  who,  if  not  properly  controlled,  will  by 
their  numerous  progeny  keep  the  schools  for  the  blind  and  deaf  people 
indefinitely.  Another  considerable  percentage  of  blindness  and  deafness 
might  have  been  prevented  by  proper  attention  in  time  to  babies'  eyes 
and  ears. 

The  prevention  of  both  the  inherited  and  the  acquired  forms  of  blind- 
ness and  deafness  will  cost  infinitely  less  than  to  support  and  educate  the 
unfortunate  victims. 

THE  COLONY  FOR  EPILEPTICS. 

The  state  of  Kansas  has  established  a  colony  for  epileptics  with  a  total 
population  of  530,  approximately  a  fourth  of  whom  are  children.  9  There 
still  remain  many  epileptics  who  should  reside  in  this  colony.  Were  the 
advantages  both  to  the  epileptic  himself  and  to  his  community  better  and 
more  widely  understood,  there  would  be  fewer  at  large. 

Epilepsy  has  thus  far  baffled  medical  science,  but  it  is  bound  to  be 
conquered  some  time,  just  as  so  many  other  diseases  have  been  and  are 
being  conquered.  Until  that  time  there  should  be  insistent  and  untiring 
research  in  every  institution  harboring  these  unfortunates.  Instead,  the 
state  of  Kansas  provides  only  custodial  care. 

CRIPPLED  AND   SICK   CHILDREN. 

The  epidemics  of  infantile  paralysis  have  left  a  trail  of  pathetic  little 
victims.  This  is  another  instance  where  highly  specialized  care  is  neces- 
sary if  the  child  is  to  be  saved  from  lifelong  helplessness.  Bone  tuber- 
culosis numbers  many  victims  who  need  orthopedic,  medical  and  hygienic 
treatment.  Various  nervous  and  constitutional  maladies  require  hospital 
care  and  sp«dal  medical  attention.  A  great  variety  of  defects  aside  from 
those  mentioned  should  have  surgical  relief. 

In  recognition  of  the  fact  that  many  children  in  many  communities 


Bulletins  Nos.  8  and  9,  August-September,  1918.        147 

were  totally  unable  to  have  proper  attention,  the  state  legislature  in 
1911  provided  a  method  by  which  parents  who  are  unable  to  pay  for 
hospital  treatment  for  their  children  might  have  them  cared  for  by  the 
hospital  of  the  University  School  of  Medicine  at  Rosedale.  But  the  appro- 
priation and  equipment  for  the  care  of  crippled  children  at  Rosedale  is 
entirely  inadequate  to  meet  the  demands. 

The  state  should  provide  the  Division  of  Child  Hygiene  with  sufficient 
funds  for  locating  these  children  and  the  University  Hospital  with  ade- 
quate facilities  for  giving  them  proper  care. 

THE   INCORRIGIBLE   CHILD. 

Population. 

Industrial  School  for  Boys,   Topeka 239 

Industrial  School  for  Girls,  Beloit 165 

Students  of  childhood  say  that  there  are  no  bad  children;  there  are 
only  misunderstood  children  and  children  who  have  never  had  a  chance 
to  be  good.  There  are  also  children  who  have  inherited  tendencies  and 
mental  limitations  which  prevent  them  from  discriminating  between  right 
and  wrong.  There  are  others  who  offend  because  of  the  incessant  irrita- 
tion and  drag  of  defective  and  undernourished  bodies.  These  children 
should  be  no  longer  punished  and  branded  with  disgrace.  They  should 
be  studied.  The  fault  usually  is  found  to  reside  not  in  the  child,  but  in 
his  inheritance  and  environment.  When  the  fault  is  in  the  child  there  is 
all  the  more  reason  to  study  him,  for  he  has  a  sick  mind  or  a  sick  body — 
often  both. 

There  is  no  greater  need  for  a  clearing-house ;  and  child-study  labora- 
tory than  in  the  case  of  the  child  who  rebels  against  his  environment 
and  wreaks  his  vengeance  upon  it  in  some  way  which  makes  it  desirable 
to  remove  him  from  it.  It  is  an  infamous  thing  to  stigmatize  such  a 
child  by  sending  him  to  a  reformatory  or  prison.  This  whole  matter 
could  be  handled  through  a  clearing-house  system  with  far  greater  justice, 
economy  and  safety  to  the  child  than  obtains  under  the  present  method 
of  commitment.  Every  child  should  automatically  be  put  in  good  physical 
condition.  This  alone  will  dispose  of  a  certain  number  of  cases.  The 
child  who  is  merely  unfortunate  and  misunderstood,  and  who  shows  char- 
acter in  resisting  a  bad  environment  in  the  only  way  he  knows,  need 
never  be  sent  to  an  institution  at  all.  He  should  be  placed  in  the  care 
of  a  discriminating  agent  and  fitted  into  the  place  he  needs — a  home. 
The  child  who  has  a  perverted  or  retarded  or  abnormal  mind  should  be 
placed  in  the(  psychopathic  department  of  the  proper  institution.  He 
should  be  studied,  and  helped  if  possible.  But  he  will  be  safe,  and  so 
will  society.  This  last  class  should  not  be  kept  with  the  children  who  can 
be  helped  and  who  are  relatively  normal.  It  is  an  injustice  to  both  classes 
of  children  and  to  the  management,  since  the  same  treatment  is  not 
applicable  to  both. 

The  weeding  out  of  the  misunderstood,  the  physically  defective,  the 
psychopathic,  the  subnormal  and  the  degenerate  will  leave  a  small  residue 
of  "difficult"  children  who  need  careful  training  and  study,  but  who  may 
become  fairly  good  citizens  under  proper  care.  This  is  the  only  legiti- 
mate use  for  a  congregate  school  of  this  sort. 


CHILD- WELFARE  LEGISLATION. 


For  the  legal  research  necessary  to  the  following  analysis  of  child-hygiene  legislation 
in  Kansas  we  are  indebted  to  Edna  Pierson  Hopkins,  LL.  B.,  Topeka. 

As  the  infant  mortality  rate  is  said  to  be  the  most  sensitive  index  we 
possess  to  social  welfare,  so  the  laws  relating  to  children  may  be  said 
to  reflect  accurately  the  social  tendencies  of  the  times.  Nothing  is  more 
significant  of  the  social  awakening  than  the  many  movements  for  the 
study  and  the  improvement  of  legislation  guarding  the  rights  of  the 
child. 

Statutes  have  mainly  to  do  with  the  protection  of  the  property  and  the 
social  rights  of  citizens,  and  the  punishment  of  offenders.  Statutes  take 
cognizance  of  the  status  of  the  child.  The  law  specifically  exempts  a 
child  of  seven  years  or  under  from  punishment  for  crime.  In  the  eyes  of 
the  law  the  child  under  seven  can  commit  no  crime.  The  law  also  recog- 
nizes the  principle  of  accountability  as  expressed  in  the  age  at  which  ma- 
jority is  attained.  Generally  at  eighteen  or  twenty-one  the  citizen  is  held 
to  be  an  adult  and  fully  accountable  before  the  law. 

What  the  law  has  not  yet  recognized  (in  line  with  the  latest  develop- 
ments in  science)  is  that  the  chronological  birthday,  eighteen  or  twenty- 
one,  does  not  indicate  necessarily  that  the  citizen  has  reached  that  age  of 
accountability.  A  twenty-first  birthday  does  not  differentiate  adequately 
between  the  minor  and  the  adult,  because  a  considerable  percentage  of 
offenders  before  the  law  never  reach  the  mental  age  of  eighteen  or 
twenty-one  nor  the  status  of  accountability  as  an  adult.  They  are  and 
always  will  be  of  the  mental  status  of  a  child,  and  so  cannot  properly  be 
held  to  account  according  to  adult  standards  of  conduct. 

In  another  respect  legislation  for  children  differs  from  average  legis- 
lation for  adults.  Child  legislation  must  look  to  the  preventive  side  of 
offenses  and  crime  rather  than  to  the  curative.  Legislation  for  children 
must  throw  such  safeguards  about  the  child,  his  home,  his  parents  or 
guardians  and  his  environment  as  to  make  offenses  against  the  law 
approximately  impossible.  To  do  this,  laws  for  children  need  to  follow 
less  the  established  procedure  or  precedence  in  law  and  to  follow  more 
the  latest  and  -best  discoveries  in  the  science  of  child  hygiene  and  welfare. 

With  the  thought  of  stimulating  an  inquiry  into  the  present  status  of 
Kansas  laws  for  children,  this  short  analysis  was  written.  Only  a  few  of 
the  more  immediately  important  laws  were  investigated,  and  of  these  a 
necessarily  incomplete  analysis  is  presented  because  of  the  short  time 
and  the  very  limited  funds  at  the  disposal  of  the  Division  of  Child 
Hygiene.  This  is  presented,  however,  with  the  hope  that  it  will  stim- 
ulate a  thorough  investigation  of  existing  legislation  for  children  in 
Kansas  and  that  eventually  a  complete  codification  of  children's  laws  may 
be  effected. 

(148) 


Bulletins  N os.  8  and  9,  August-September,  1918.        149 


Birth  Registration. 

Scarcely  a  day  passes  but  that  some  bewildered  individual  comes  to 
the  vital  statistics  office  of  the  State  Board  of  Health  seeking  proof  that 
he  is  an  American  citizen  and  a  Kansan. 

France  has  had  complete  and  accurate  records  of  her  citizens  since 
1687.  Kansas  has  records  dating  only  to  1911.  In  order  to  make  avail- 
able a  permanent  record  of  the  birth  of  every  Kansan  the  State  Board 
of  Health  is  establishing  files  antedating  1911  and  sufficiently  complete  to 
include  every  citizen  who  will  avail  himself  of  the  privilege  of  registering. 
These  records  will  become  increasingly  important  to  succeeding  gen- 
erations. 

Following  the  close  of  the  great  war  hundreds  of  claims  of  various 
kinds  will  appear,  in  the  settlement  of  which  a  demand  is  likely  to  be 
made  for  a  certificate  of  birth  as  proof  of  citizenship.  If  this  certificate 
were  on  file  with  the  Kansas  State  Board  of  Health  it  could  be  had  in  a 
few  minutes'  time.  If  it  is  not  on  file  the  claimant  will  be  required  to  go 
to  considerable  effort  and  expense  to  furnish  the  proper  proofs. 

A  birth  certificate  is  now  required  to  obtain  a  passport  to  a  foreign 
country,  to  obtain  a  soldier's  pension,  and  to  establish  American  citizen- 
ship. , 

A  birth  certificate  may  be  required  to  establish  identity,  to  enter  school, 
to  employment  under  child  labor  laws,  to  inherit  property,  to  establish 
liability  for  military  service  and  exemption  therefrom,  to  vote,  to  hold 
title,  to  buy  or  sell  real  estate,  to  marry. 

In  order  to  make  the  importance  of  birth  registration  more  generally 
known  and  Kansas  records  more  complete,  a  request  was  sent  to  school 
authorities  asking  that  they  require  a  birth  certificate  as  proof  of  age 
when  entering  school.  As  a  further  check  on  the  birth  registration,  the 
Department  of  Labor  requested  county  and  city  superintendents  of 
schools  to  require  a  birth  certificate  in  granting  work  permits  to  children. 
With  these  two  checks  through  the  school  authorities,  Kansas  birth 
registration  should  be  made  practically  complete. 


Mothers'  Pension  Act. 

The  problem  of  poverty  exerts  a  marked  influence  on  child  mortality. 
Whenever  the  standard  of  living  drops  to  or  below  the  border  line  of 
economic  security,  immediately  the  death  rate  of  minor  children  begins 
to  rise.  When  the  father  as  a  principal  breadwinner  is  absent  and  the 
mother  compelled  to  take  both  a  father's  and  mother's  place,  the  problem 
is  still  further  complicated  by  an  additional  increase  in  child  mortality 
and  an  increase  of  juvenile  delinquency  as  a  result  of  the  lack  of  watch- 
ful care  of  a  mother. 

In  recognition  of  this  condition  and  to  a  somewhat  less  extent  in 
recognition  of  mother's  service  to  her  state  in  producing  children, 
the  mothers'  pension  acts  came  into  existence.  The  Kansas  mothers' 


150  Kansas  State  Board  of  Health. 

pension  act,  as  it  now  reads  in  Session  Laws  of  1917,  is  "An  act  to  amend 
chapter  261  of  the  Session  Laws  of  1915,  the  same  being  an  act  to  amend 
section  6624  of  the  General  Statutes  of  1915,  relating  to  the  poor,  for 
the  relief  of  widows  and  dependent  children,  and  repealing  said  original 
section.  This  act  provides  that  the  board  of  county  commissioners  may, 
in  their  discretion,  allow  and  pay  to  poor  persons  who  may  become 
chargeable  as  paupers  such  annual  allowances  as  will  not  exceed  the 
charge  of  their  maintenance  in  the  ordinary  mode.  Such  allowances  are 
to  be  paid  from  the  funds  in  the  general  revenue  fund  of  the  county. 

In  order  to  obtain  a  knowledge  of  the  practical  workings  of  this  law 
a  questionnaire  letter  was  sent  to  numerous  counties  asking  for  the 
number  of  mothers  helped,  the  amount  of  money  paid  out  for  pensions 
by  the  county,  the  type  of  women  given  assistance,  and  the  attitude  of 
the  commissioners  toward  giving  pensions.  A  digest  of  the  answers 
follows : 

County  A  Reports:  There  are  no  mothers  receiving  the  pension,  but 
about  $400  is  paid  out  each  month  to  the  poor  of  the  county.  None  of 
this  money  is  paid  under  the  provisions  of  the  mothers'  pension  act. 

County  B  reports:  Seven  mothers  were  given  assistance  during  the 
year.  The  amount  of  money  paid  out  was  $804.  Good,  hard-working 
women  were  given  the  pensions.  The  attitude  of  the  commissioners 
toward  the  pensions  reported  as  being  all  that  could  be  desired. 

County  C  reports:  Commissioners  are  opposed  to  giving  pensions, 
because  the  county  is  an  industrial  center  and  there  are  so  many  widows 
that  the  commissioners  say  it  would  bankrupt  the  county  to  begin  giv- 
ing pensions.  The  question  is  asked  from  this  county,  whether  or  not 
the  law  would  be  more  effective  if  the  fund  were  provided  by  the  state 
instead  of  each  individual  county.  They  suggest  that  as  the  state  reaps 
the  benefit  from  these  industrial  counties,  it  should  share  the  responsi- 
bility. 

County  D  reports :  Six  pensions  were  given  during  the  year.  Amount 
paid  out,  $564.  Commissioners  are  very  slow  to  give  pensions  on  account 
of  lack  of  funds  in  the  county.  Type  of  women  given  aid  are  unfor- 
tunates who  are  left  with  large  families  to  support. 

County  E  reports:  Work  progressing  well,  but  commissioners  more 
or  less  hampered  in  the  giving  of  pensions  by  the  lack  of  funds. 

Further  reports  and  interviews  with  women  appointed  to  investigate 
applications  for  funds  under  this  act  concede  the  same  essential  details : 
That  the  county  commissioners  as  a  whole  would  favor  the  granting  of 
mothers'  pensions  if  they  had  a  definite  fund  to  draw  from ;  that  trained 
supervision  of  investigations,  and  uniformity  of  method  is  desirable. 

The  adoption  of  a  mothers'  pension  act  in  Kansas  was  a  big  step  for- 
ward. But  it  is  not  enough  merely  to  place  an  act  on  the  statute 
books — the  law  must  be  a  workable  one  and  provisions  must  be  made  to 
have  it  carried  out  in  proper  spirit  of  the  statute.  Nor  should  any  act 
be  permitted  to  lose  its  force  because  of  lack  of  funds  by  which  it  may 
be  administered  and  the  provisions  carried  out. 


Bulletins  Nos.  8  and  9,  August-September,  1918.        151 

The  Kansas  mothers'  pension  law  as  it  now  stands  nee'ds  further  study 
as  to  the  provision  of  funds  by  which  the  law  will  become  effective,  and 
as  to  the  methods  of  administering  which  will  carry  out  the  purposes 
for  which  the  act  was  intended. 


Children  Born  Out  of  Wedlock. 

The  Declaration  of  Independence  declares  all  men  to  be  born  free  and 
equal ;  the  constitution  of  the  United  States  guarantees  to  all  life,  liberty 
and  the  pursuit  of  happiness.  Neither  specifically  excludes  the  child  born 
out  of  wedlock.  Yet  if  a  child  is  so  indiscreet  as  to  be  born  without  a  mar- 
riage certificate  having  first  been  obtained  by  his  parents  he  is  deprived 
of  a  natural  home,  parental  care,  guardianship  and  sustenance,  and  he 
stands  condemned  as  a  quasi-criminal  throughout  his  life. 

Laws  affecting  children  born  out  of  wedlock  are  a  heritage  along  with 
the  rest  of  the  common  law.  The  Napoleonic  code  not  only  gave  the  child 
born  out  of  wedlock  no  rights,  but  it  forbade  any  inquiry  into  its  paternity. 
The  common  law  of  England,  failing  to  stop  illegitimacy  by  punishment  of 
the  women,  visited  the  punishment  upon  the  innocent  child  by  declaring  it 
to  be  "the  child  of  no  one"  (filius  nullius) ,  and  entirely  relieved  those  who 
gave  life  to  it  from  all  responsibility.  Later  laws  were  enacted  regarding 
illegitimacy,  not  with  a  view  of  doing  the  innocent  child  justice  but  as  a 
part  of  the  poor  laws,  with  a  view  to  protecting*  the  community  on  which 
fell  the  burden  of  the  child's  support. 

The  law  concerning  illegitimate  children  in  many  parts  of  the  United 
States,  including  Kansas,  still  stigmatizes  a  child  born  out  of  wedlock  as  a 
"bastard."  In  Kansas  an  unmarried  mother  who  is  delivered  of  or  preg- 
nant with  a  "bastard"  child  may  make  a  complaint  in  writing  before  a 
justice  of  the  peace  charging  the  father  of  her  child,  who  is  thereupon  ar- 
rested and  brought  before  the  magistrate.  If  the  case  is  sufficiently  clear 
the  accused  man  is  held  for  trial  before  the  district  court.  If  the  de- 
fendant denies  the  charge,  the  trial  must  be  by  jury. 

These  cases  are  tried  in  open  court,  usually  with  a  large  and  interested 
audience.  The  girl  is  subject  to  severe  and  often  shocking  examination 
and  cross-examination.  A  common  form  of  defense  is  to  attack  and  try 
to  tear  down  her  previous  good  character,  often  going  to  the  length  of  in- 
troducing several  witnesses  for  the  defense  to  swear  to  improper  relations 
with  the  girl  in  order  to  throw  in  doubt  the  paternity  of  the  child.  If  the 
girl  is  successful  in  her  suit,  the  man  is  adjudged  the  father  of  the  child 
and  is  charged  with  its  maintenance  and  education.  If  he  fails  to  do  so, 
he  may  be  sent  to  jail,  but  not  for  more  than  one  year.  If  in  the  mean- 
time he  should  leave  the  state,  there  is  no  law  for  bringing  him  back  as  in 
the  case  of  stealing  a  horse  or  selling  a  jug  of  whiskey,  unless  he  should 
be  charged  also  with  criminal  action. 

The  law  primarily  .does  not  protect  the  child  and  the  mother,  but 
the  possible  father.  She  and  her  child  are  guilty.  He  is  guilty  only  if 
she  can  prove  it.  And  the  length  of  publicity  and  public  humiliation  to 
which  she  must  go  in  order  to  prove  paternity  and  obtain  support  for  her 
child  is  scarely  worth  the  effort.  If  the  mother  is  ignorant  of  the  law, 


152  Kansas  State  Board  of  Health. 

or  if,  as  the  case  often  happens,  she  is  poor  and  without  friends  or  is  of 
low  mentality,*  she  can  obtain  no  redress  whatever. 

As  a  result  of  this  condition,  a  girl  who  finds  herself  in  trouble 
generally  flees  to  a  distant  city  to  hide  her  shame.f  Often  she  does  not 
give  her  right  name.  She  goes  to  the  hospital  alone,  and  there  alone 
she  brings  forth  her  child.  When  she  has  again  recovered  her  strength, 
she  goes  on  her  way  alone.  Or,  with  a  courage  beside  which  ordinary 
heroic  achievements  pale  into  insignificance,  she  takes  up  the  unequal 
burden  of  supporting  them  both — she  an  "outcast"  of  society,  her  child 
a  "bastard"  before  the  law. 

One  of  the  most  potent  signs  of  the  awakening  social  consciousness  is 
the  agitation  for  an  improvement  of  the  conditions  of  the  unmarried 
mother  and  her  child.  One  proposed  remedy  which  has  received  a  great 
deal  of  public  attention  is  the  so-called  Castberg  law,  now  in  force  in 
Norway.  Under  the  Castberg  law  the  burden  of  proof  is  thrown  upon 
the  reputed  father,  who  is  guilty  until  he  proves  his  innocence.  If  more 
than  one  man  may  be  the  possible  father  of  the  child,  each  may  be  held 
liable  to  contribute  to  its  support. 

Any  proposed  statute  for  the  protection  of  a  child  born  out  of  wedlock 
should  provide  for  the  legal  status  of  the  child,  its  maintenance  and 
education,  and  should  relieve  the  mother  of  the  cost  and  entire  responsi- 
bility for  the  action.  The  guiding  spirit  of  such  a  law  should  be  the 
welfare  of  the  child.  To  this  end  the  court  should  be  empowered  to  decree 
whether  the  child  takes  the  name  of  the  father  or  the  mother,  how  much 
each  shall  contribute  to  his  suport,  including  cost  of  confinement  and  cost 
of  suit,  which  one  shall  have  the  custody  of  the  child,  and  all  such  other 
necessary  power  to  give  the  child  all  its  legal  rights  as  though  it  were 
born  of  lawful  wedlock. 

Laws  now  enacted  by  progressive  states  provide  that  any  interested 
person  (by  permission  of  the  court)  may  bring  action  to  determine 
paternity;  that  the  service  may  be  obtained  by  publication  instead  of 
arrest  and  the  case  heard  in  closed  court,  that  the  evidence  may  be  sealed, 
and  that  the  right  of  extradition  be  provided.  Should  the  court  find  the 
defendant  to  be  the  real  father  of  the  child,  it  enters  a  decree  that  the 
child  is  to  all  legal  intents  and  purposes  the  child  of  the  natural  father 
and  entitled  to  all  the  rights  pertaining  thereto. 


Abuse  of  Children. 

A  man  who  cruelly  assaults  and  beats  a  defenseless  child  merits  the 
suspicion  that  he  is  either  under  the  influence  of  alcohol  or  drugs,  or 
that  he  is  insane  or  degenerate.  Such  a  man  is  not  a  safe  person  to  be 
at  large  in  the  community. 

Under  the  Kansas  law  (section  6403,  General  Statutes  of  1915)  the 
offense  of  assault  of  a  child  is  still  regarded  as  only  a  misdemeanor.  The 

*  "The  result  of  two  separate  tests  leads  to  the  conclusion  that  not  more  than  20  percent 

of  the  unmarried  mothers  cared  for  by  the  obstetrical  service  of  General  Hospital 

may  safely  be  pronounced  normal."  From  Mentality  of  the  Unmarried  Mother  by  Jean 
West,  Asst.  Director,  Psychological  Clinic. 

t  Girls  from  neighboring  states  come  to  Kansas.  Kansas  girls  go  to  Missouri,  Okla- 
homa and  Colorado. 


Bulletins  Nos.  8  and  9,  August-September,  1918.        153 

maximum  penalty  is  a  fine  of  $250  and  imprisonment  in  the  county  jail 
for  a  term  not  to  exceed  one  year. 

Inadequate  as  this  statute  is,  in  actual  practice  the  offender  may  be 
let  off  with  a  very  much  lighter  sentence  if  he  is  apprehended  by  the 
police  and  brought  to  trial  in  a  police  court.  Although  the  district  court 
has  concurrent  jurisdiction,  the  -county  attorney  as  a  rule  does  not 
prosecute  a  man  who  has  already  been  convicted  in  police  court  on  a 
charge  of  this  nature. 

Attention  was  catted  to  this  unfortunatly  common  method  of  pro- 
cedure and  to  the  inadequacy  of  the  present  statute  by  the  case  of  Ollie 
Bussy,  who  was  arrested  and  convicted  of  cruelly  beating  an  eighteen- 
months-old  baby.  Competent  testimony  established  the  fact  that  the  child 
had  been  most  outrageously  and  atrociously  assaulted.  The  judge  im- 
posed a  fine  of  $100,  the  maximum  penalty  under  city  ordinance  1203, 
Revised  Ordinances,  City  of  Topeka,  1916.  Upon  investigation  it  was 
found  that  Ollie  Bussy  had  had  a  long  criminal  record,  and  that  at  the 
time  he  was  on  parole  from  the  penitentiary.  He  was  returned  promptly 
to  the  Penitentiary  on  violation  of  his  parole. 

Had  Ollie  Bussy  not  been  on  parole,  and  his  parole  not  been  revoked, 
the  only  punishment  he  would  have  received  for  the  offense  of  beating 
a  helpless  baby  would  have  been  the  $100  fine.  Had  the  county  attorney 
also  prosecuted  him  he  might  have  received  an  additional  fine  of  $250 
and  imprisonment  of  not  more  than  one  year  in  the  county  jail,  which 
altogether  does  not  seem  an  adequate  sentence  for  this  crime. 

What  has  happened  in  Topeka  can  happen  elsewhere,  and  probably  is 
happening.  To  brutally  assault  a  child  is  such  a  heinous  offense  that 
whenever  such  cases  come  before  the  attention  of  the  citizens  or  police 
they  ought  at  once  -to  lay  the  evidence  before  the  county  attorney 
in  order  that  the  offender  may  be  given  immediately  the  maximum  penalty 
of  the  law. 

Crimes  against  children  aptly  illustrate  the  inadequacy  and  incom- 
petency  of  the  present  procedure  in  law  as  to  the  punishment  of  crime. 
The  whole  modern  tendency  of  science  is  towards  prevention  rather  than 
cure  or  punishment.  The  proper  protection  of  children  demands  that  the 
law  keep  abreast  of  science. 

When  Ollie  Bussy  committed  his  first  offense  in  all  probability  he 
would  have  been  recommended  by  a  psychologist  for  permanent  custodial 
care.  Certainly  after  a  proper  examination  into  his  mental  condition 
he  would  not  have  been  released  from  custody  repeatedly,  only  to  commit 
other  and  more  serious  offenses  for  which  he  must  be  retried  and  re- 
sentenced.  The  cost  of  such  procedure  undoubtedly  is  many  times  that 
of  the  preventive  method,  and  furthermore  so  clumsy  and  inefficient  that 
it  ought  not  to  be  tolerated. 

The  remedy  in  the  law  may  be  through  the  establishment  of  a  state 
bureau  of  mental  examination,  accessible  to  all  courts,  with  provision 
in  court  for  the  appointment  of  a  qualified  mental  examiner.  When  a 
mentally  irresponsible  person  with  criminal  instincts  is  once  apprehended 
he  should  be  retained  in  permanent  custody  of  the  state.  Such  a  pro- 
cedure would  prevent  the  majority  of  repetitions  of  offense  and  violations 
of  parole  which  contribute  to  a  long  criminal  record. 


154  Kansas  State  Board  of  Health. 


Care  of  Feeble-minded  Children. 

Feeble-mindedness  is  an  inheritable  defect.  No  normal  child  ever  has 
been  born  to  feeble-minded  parents.  If  one  parent  is  feeble-minded  and 
the  other  is  normal  the  child  has  about  an  even  chance  of  being  feeble- 
minded or  apparently  normal.  This  normal  child,  however,  transmits 
feeble-mindedness  to  his  offspring,  and  a  certain  percent  of  them  will  be 
feeble-minded. 

To  permit  a  feeble-minded  or  otherwise  mentally  irresponsible  person 
to  have  offspring  is  a  rank  injustice  to  the  child,  to  the  parent  and  to  the 
state.  Common  justice  and  fairness  demand  that  a  feeble-minded  child  or 
child  of  mentally  irresponsible  persons,  having  once  been  born,  be  given 
every  opportunity  for  the  fullest  possible  development  of  his  feeble  talents. 
This  is  necessary  to  make  him  self-repecting  and  self-supporting,  and  to 
give  him  a  small  measure  of  happiness  which  is  a  poor  enough  return  for 
the  injustice  already  inflicted  upon  him. 

The  legislative  committee  of  the  Kansas  Commission  on  Provision  for 
the  Feeble-Minded  investigated  the  existing  legislation  regarding  feeble- 
mindedness in  this  state.  The  following  is  an  excerpt  from  their  report. 
A  full  report  of  the  Commission  will  be  published  later: 

"Session  Laws,  1881,  chapter  35  (section  9671,  G.  S.  1915),  established 
an  institution  for  the  education  of  idiots  and  imbecile  children,  to  be  de- 
nominated the  'Kansas  State  Asylum  for  Idiotic  and  Imbecile  Youth.' 
Session  Laws,  1909,  chapter  233,  changed  the  name  of  the  institution  to 
the  'State  Home  for  the  Feeble-Minded.'  The  institution  was  originally 
intended  to  be  a  training  school  for  these  unfortunate  children.  As  there 
has  been  no  sufficient  provision  for  educating  such  children  as  might  be 
trained,  it  has  been  permitted  to  become  a  custodial  asylum  for  low- 
grade  feeble-minded. 

"A  larger  appropriation  is  necessary  to  provide  a  modern  training 
school  at  Winfield  and  to  establish  colonies  in  order  to  segregate  properly 
the  various  grades  of  feeble-minded  into  such  groups  as  would  best  fa- 
cilitate their  training  and  care.  In  connection  with  this  training  school  a 
properly  equipped  medical  and  psychological  clinic  should  be  established 
to  give  these  children  the  most  favorable  classification  and  treatment.  If 
this  were  done,  parents  of  mentally  backward  or  feeble-minded  children 
would  cheerfully  send  their  children  for  such  special  training  as  they  re- 
quire, just  as  parents  now  send  their  children  to  the  State  School  for  the 
Blind  or  Deaf.  This  would  better  the  condition  of  the  children  and  re- 
lieve the  communities  of  hundreds  who  are  now  a  drag  in  the  school  room, 
who  exercise  a  degenerating  influence  on  the  younger  children  with  whom 
they  are  associated,  and  who,  as  they  grow  older,  constitute  a  steady  and 
constant  stream  of  petty  criminals. 

"Admission  to  the  Winfield  institution  is  now  on  application  of  parent 
or  guardian.  There  being  no  commitment  law  in  the  state,  no  court  has 
the  authority  to  commit  a  feeble-minded  person,  even  though  he  may  be  a 
public  nuisance  or  menace.*  Frequently  it  happens  that  the  parent  or 

*  Section  6098,  General  Statutes  of  1915,  provides  for  inquiry  to  be  made  when 
verified  information  in  writing  is  given  that  any  resident  of  a  county  is  insane,  a  lunatic, 
an  idiot,  an  imbecile,  a  feeble-minded  person,  drug  habitue  or  habitual  drunkard,  and  for 
any  of  these  reasons  is  incapable  of  managing  his  affairs. 

Section  6100,  General  Statutes  of  1915,  provides  that  if  the  jury  impaneled  to  try  the 
case  finds  that  the  person  is  insane,  a  lunatic,  an  idiot,  an  imbecile,  a  distracted  person, 
a  feeble-minded  person,  a  drug  habitue,  an  habitual  drunkard,  or  one  incapable  of  manag- 
ing his  affairs  and  in  need  of  a  guardian,  the  court  may,  if  it  finds  that  such  order  is 
necessary,  appoint  a  guardian  of  the  person  or  estate  of  such  person,  or  both,  as  the 
circumstances  of  the  case  may  require. 

Section   6107,   General  Statutes  of   1915,   provides  that  every  probate  court  by  whom 


Bulletins  Nos.  8  and  9,  August-September,  1918.        155 

guardian  (if  he  be  a  relative)  of  the  feeble-minded  person  is  of  such  low- 
grade  intelligence  that  he  himself  is  a  proper  person  for  custodial  care. 
The  absurdity  of  the  lack  of  proper  commitment  power  by  the  courts  im- 
mediately becomes  apparent. 

"The  legislative  committee  therefore  recommends : 

"First:  That  the  name  of  the  State  Home  for  Feeble-minded  be 
changed  to  the  State  Training  School,  and  that  sufficient  appropriation 
be  made  to  restore  the  original  purpose  of  the  institution. 

"Second:  That  a  proper  commitment  law  for  feeble-minded  be  en- 
acted, enabling  the  state,  when  the  best  interests  of  society  or  the  in- 
dividual demand  to  transfer  a  feeble-minded  child  or  adult  to  this  institu- 
tion. 

"Such  legislation,  and  sufficient  appropriation  to  carry  it  out,  both  as  to 
the  letter  and  the  spirit  of  the  law,  would  enable  Kansas  to  care  for  the 
feeble-minded  in  a  scientific  manner,  and  in  the  way  demanded  by 
modern  ideas  for  the  care  of  these  unfortunates." 


Physical  Inspection  of  School  Children. 

Before  starting  on  a  long  journey  the  careful  automobilist  makes  cer- 
tain that  his  machine  is  in  perfect  condition  for  the  trip.  Even  starting 
with  a  perfect  machine,  a  long  trip  is  likely  to  bring  out  or  develop  un- 
suspected defects.  Just  as  logical  as  the  careful  inspection  and  repair  of 
an  automobile  preparatory  to  a  trip  is  the  examination  and  treatment  of 
the  defects  of  a  child  before  starting  to  school  each  year.  A  parent  or 
guardian  of  a  school  child  needs  to  be  certain  that  the  child  can  see  well, 
that  he  hears  well,  that  his  teeth  are  good,  and  that  he  is  free  from  defects 
which  will  interfere  with  his  health  and  school  progress. 

But  granted  that  a  child  starts  to  school  in  perfect  condition,  a  parent 
has  no  assurance  that  his  child  will  not  come  in  contact  with  children  who 
have  not  had  such  ca^re.  Neither  has  he  any  assurance  that  his  child  will 
not  be  exposed  to  contagious  diseases  or  to  conditions  which  may  be 
attended  with  unpleasant  if  not  dangerous  consequences.  The  majority 
of  all  children  attending  school  are  without  proper  protection  from  the 
spread  of  communicable  diseases,  and  their  minor  physical  ailments  are 
undiscovered  and  neglected.  Only  a  few  states  and  a  few  large  cities  have 
made  legal  provision  for  periodic  inspection  of  school  children,  and  still 
fewer  of  them  are  providing  adequate  methods  of  treatment.  This  legal 
protection  should  be  extended  with  all  possible  rapidity  until  every  child 
in  the  country  is  thus  safeguarded.  No  parent  can  feel  secure  as  to  the 
health  protection  of  his  own  child  until  all  the  children  with  whom  his 
child  comes  in  contact  are  also  protected  from  contagion  and  from  all 
conditions  coincident  with  school  life  which  affect  the  health  of  any  child 
unfavorably. 

Sections  9099  and  9100,  General  Statutes  of  1915,  provide  for  the  ex- 
penditure of  school  funds  for  dental  inspection  in  cities  of  40,000  or  over. 
These  sections  should  be  enlarged  to  permit  all  school  boards  to  use  school 
funds  for  the  employment  of  school  nurses,  doctors  and  dentists,  for  the 
establishment  of  school  clinics,  and  for  such  other  measures  as  will  insure 
the  complete  protection  of  all  school  children. 

any  such  person  is  committed  to  guardianship  may  make  an  order  for  the  support,  care 
and  safe-keeping  of  such  person.  In  this  roundabout  way  the  guardian  and  the  probate 
court  may  send  the  person  to  Winfield. 


156  Kansas  State  Board  of  Health. 


Marriage. 

The  prevalence  of  divorce  and  the  numbers  of  children  of  ill-considered 
and  unfit  marriages,  handicapped  at  the  start  by  mental,  physical  and 
economic  limitations,  compels  the  conclusion  that  marriage  is  not  ade- 
quately safeguarded  by  law. 

Many  of  the  spur-of-the-moment  and  ill-advised  marriages  would  be 
prevented  if  the  statutes  required  a  five  days'  notice  for  the  issuing  of  the 
marriage  license.  Several  of  the  states  already  have  legislation  along 
this  line. 

Wisconsin  requires  that  not  less  than  five  days  previous  to  persons 
being  joined  in  marriage  a  license  shall  be  obtained  from  the  county 
clerk  of  the  county  in  which  the  female  resides,  or  if  not  a  resident  of 
the  state,  then  from  the  county  where  the  marriage  is  to  take  place  in  the 
state.  In  addition  Wisconsin  requires  a  health  certificate  certifying  that 
the  male  applying  for  the  license  has  been  examined  with  fifteen  days 
prior  to  application  for  license  to  marry,  and  is  free  from  veneral  disease. 
Massachusetts  and  New  Hampshire  also  require  a  five  days'  notice  for  a 
marriage  license. 

The  Missouri  children's  code  commission  recommends  that  common-law 
marriages  be  abolished,  and  that  there  should  be  an  interval  of  five  days 
between  the  application  for  a  marriage  license  and  its  issuance.  The 
marriage  of  feebleminded,  epileptic  and  insane  is  already  prohibited. 

Kansas  forbids  the  contracting  of  marriage  within  prohibited  degrees 
of  relationship.  It  also  forbids  the  issuance  of  a  license  to  epileptics 
unless  the  female  is  over  forty-five  years  of  age,  and  the  marriage  of  the 
insane,  but  there  is  no  provision  for  the  necessary  supervision  aa  to  make 
these  laws  effective.  Ultimately  Kansas  should  provide  that  no  marriage 
license  may  be  issued  until  both  parties  present  certificates  of  mental  and 
physical  fitness  for  caring  for  themselves  and  their  progeny,  and  in  every 
case  there  should  be  at  least  five  days'  notice  of  the  intended  marriage. 


Compulsory  Education  and  Child  Labor. 

According  to  the  federal  census  of  1910,  6,857  Kansas  children  be- 
tween the  ages  of  ten  and  thirteen  are  at  work.  The  undesirable  char- 
acter of  jobs  offered  to  children  who  leave  school  early  causes  them  to 
change  their  employment  constantly.  By  so  doing  they  acquire  habits  of 
shifting,  which  habits  are  not  only  hard  to  overcome,  but  leave  an  un- 
desirable mark  on  their  character. 

Every  year  23,000  American  children  between  the  ages  of  nine  and 
fifteen  are  injured,  crippled  or  lose  their  lives  by  playing  in  other  dan- 
gerous places  and  by  accidents  in  industry.  In  addition  to  the  di- 
rect injuries  to  the  young  child  in  industry,  he  is  likely  to  be  so 
injured  in  body  and  so  stunted  in  mind  by  the  long  hours  and  unhealth- 
ful  conditions  that  in  later  life  he  finds  it  impossible  to  compete  success- 
fully with  the  more  fortunate  workers  who  were  protected  in  childhood. 


Bulletins  Nos.  8  and  9,  August-September,  1918.        157 

The  federal  child-labor  law,  which  offered  direct  protection  to  more 
than  150,000  children,  was  recently  declared  unconstitutional.  These 
'children  are  now  without  any  protection  except  such  as  their  respective 
states  afford  them.  Perhaps  one  of  the  best  protections  against  child 
labor  and  its  attendant  degenerating  influences  on  childhood  is  a  good 
compulsory  education  law  rigidly  enforced.  The  census  of  1910  reports 
28,968  illiterates  over  ten  years  of  age  in  Kansas. 

Section  9415,  General  Statutes  of  1915,  provides  that  every  parent, 
guardian,  or  other  person  in  the  state  of  Kansas  having  control  or  charge 
of  any  child  or  children  between  the  ages  of  eight  and  fifteen  years,  in- 
clusive, shall  be  required  to  send  such  child  or  children  "to  a  public 
school  or  a  private,  denominational  or  parochial  school,  taught  by  a 
competent  instructor,  each  school  year  for  such  period  as  said  school 
is  in  session."  The  age  limit  in  this  section  has  been  enforced  heretofore 
to  the  fifteenth  birthday. 

The  attorney-general  gave  an  opinion  May  28,  1916,  on  section  9415 
as  follows:  "In  my  judgment  it  includes  those  (children)  between  their 
eighth  and  sixteenth  birthdays.  The  language  without  the  word  'in- 
clusive' would  include  all  children  between  their  eighth  and  fifteenth 
birthdays,  and  it  was  evidently  the  intention  of  the  legislature,  by  the 
use  of  the  word  'inclusive,'  to  include  those  in  the  sixteenth  year;  other- 
wise the  word  'inclusive'  would  have  no  meaning.". 

The  attorney-general  goes  on  to  state  in  the  same  opinion  that  chapter 
227,  Session  Laws  of  1917,  generally  spoken  of  as  the  "child-labor  act," 
controls  and  limits  section  9415,  since  legally  no  child  under  the  age  of 
sixteen  can  be  regularly  employed  in  any  of  the  occupations  mentioned 
in  the  act  unless  he  has  the  work  permit,  which  permit  he  cannot  have 
unless  he  has  completed  the  course  of  study  prescribed  for  elementary 
schools. 

This  opinion  properly  connects  the  two  laws  as  they  should  be,  and 
removes  the  discrepancy  which  has  caused  so  much  trouble  in  the  enforc- 
ing of  both  laws.  The  state  of  Kansas  is  now  in  a  position  to  put  into 
effect  at  once  a  most  modern  law  for  the  education  of  children.  With 
the  cooperation  of  parents,  employees  and  school  authorities,  standards 
may  be  promoted  which  will  further  advance  the  welfare  of  Kansas 
children. 


Adoption. 

The  best  interests  of  children  and  of  society  demand  that  every  child 
have  a  good  home.  Where  a  child  is  deprived  of  his  natural  home  by 
reason  of  death  or  disability  of  his  parents,  the  law  provides  means  by 
which  he  may  be  taken  by  foster  parents  and  become  an  actual  member 
of  their  family,  entitled  to  all  the  rights  and  privileges  of  a  natural  child. 

In  Kansas,  section  6361,  General  Statutes  of  1915,  provides  for  the 
relinquishment  of  parental  rights  by  the  natural  parent.  In  this  sec- 
tion it  is  contemplated  that  relinquishment  shall  be  had  in  the  court  of 
the  county  where  the  natural  parent  resides. 

Section  6362  deals  with  the  adopting  parents,  and  provides  that  any 
person  may  go  into  the  probate  court  of  a  county  in  which  he  resides  and 


158  Kansas  State  Board  of  Health. 

offer  to  adopt  a  child.  When  the  adopting  parents  live  in  one  county  and 
the  natural  parents  live  in  another,  the  question  arises  whether  an  adop- 
tion proceeding  can  be  split  up,  part  of  it  being  made  in  one  county  and 
part  in  another. 

Section  6362  also  provides  that  the  "court  shall  investigate  the  matter," 
and  if  the  probate  court  "on  investigation  finds  the  person  offering  to 
adopt  some  minor  child  is  unfit  or  financially  unable,"  such  court  shall 
refuse  to  permit  such  adoption  to  be  made.  The  spirit  of  this  section  is 
clear,  but  there  is  no  provision  made  in  any  section  relating  to  adoption 
for  the  making  of  such  investigation,  other  than  for  the  judge  to  require 
such  persons  to  appear  before  him  for  such  personal  inquiry  as  he  is 
able  or  inclined  to  make. 

Section  6369  provides  that  parents  may  relinquish  their  children  to 
corporations  authorized  to  receive  children.  This  relinquishment  is  in 
writing,  and  the  corporation  acquires  the  legal  custody  of  the  child. 

Sections  6369  and  6361  not  being  connected,  child-placing  agencies, 
wholly  in  good  faith,  have  acted  upon  the  assumption  that  section  6369 
was  sufficient  by  itself.  This  has  led  to  difficulties  in  the  way  of  proving 
inheritance  to  property,  the  court  holding  that  adoption  by  contract 
between  parties  is  not  sufficient  to  make  the  child  the  legal  heir  of  the 
adopting  parties.  (See  98  Kansas,  620.) 

In  a  matter  so  vitally  important  as  the  relinquishment  and  adoption  of 
children  it  is  very  necessary  that  the  laws  be  so  clear  and  concise  that 
they  leave  no  room  for  doubt  or  misinterpretation.  An  irregular  adop- 
tion may  lead  to  very  serious  difficulties  in  the  inheritance  of  property 
and  the  establishment  of  other  legal  rights. 

The  investigation  of  possible  homes  for  orphaned  and  destitute  chil- 
dren, and  the  investigation  of  such  children  physically,  mentally  and 
socially  as  to  their  fitness  for  adoption  into  normal  homes  presents 
another  very  difficult  problem.  Neither  the  courts,  children's  institutions, 
child  placing  societies  nor  the  state  is  at  present  equipped  to  undertake 
such  necessary  investigations  as  to  prevent  injustices  to  the  children  and 
the  homes  into  which  they  are  adopted.  And  under  the  present  system 
it  is  not  possible  for  such  investigation  and  records  as  may  have  been 
made  by  one  society,  court  or  state  to  be  made  available  to  all  the  other 
societies,  organizations  or  courts  that  may  become  interested  in  a  given 
child  or  family. 

The  whole  problem  of  supporting  and  educating  the  child  wards  of  the 
state  is  at  present  in  a  chaotic  condition.  Helpless  infants  and  children 
are  being  exploited  in  unlicensed  boarding  homes,  or  cared  for  in  meagerly 
supported,  badly  managed,  unstandardized  private  institutions,  or  con- 
signed to  the  custody  of  state  institutions  which  are  not  up  to  modern 
standards — institutions  which  are  too  prone  to  put  an  institutional  stamp 
upon  the  child,  institutions  in  which  the  same  atmosphere  of  repression 
prevails  that  is  found  in  penal,  correctional  and  insane  institutions. 

The  whole  plan  needs  revision,  so  that  it  will  become  comprehensive 
enough  to  bring  all  helpless  minor  children  under  direct  custody  of  the 
state,  and  organic  and  scientific  enough  that  the  state  will  be  able  to  give 
every  one  of  these  potential  citizens  a  square  deal  and  assure  itself  of  a 
definite  unit  of  good  citizenship. 


Bulletins  Nos.  8  and  9,  August-September,  1918.        159 


Licensing  Homes  for  Children,  and  Maternity  Homes. 

The  statutes  of  Kansas  require : 

A  license  to  run  a  private  boarding  house  for  adults;  no  license  for 
conducting  a  private  boarding  house  for  helpless  children. 

A  license  to  run  a  private  hotel  for  adults;  none  for  operating  a  paying 
institution  for  children.  , 

A  license  to  operate  a  private  hospital  for  sick  or  insane;  none  for  op- 
erating a  private  hospital  for  expectant  mothers  and  their  helpless  babies. 

In  other  words,  the  Kansas  statutes  specifically  protect  adults  from 
insanitary  surroundings  and  from  being  exploited,  but  it  makes  no  such 
provision  for  helpless  babies  and  children  in  private  institutions. 

Any  incorporated  institution  in  the  state  of  Kansas  must  apply  for 
and  be  granted  a  charter  from  the  State  Charter  Board.  The  statute 
provides  for  the  inspection  by  the  State  Board  of  Administration  of 
private,  charitable  institutions  receiving  state  aid  (section  9586,  statutes 
of  1915,  and  for  those  soliciting  funds  outside  of  their  own  county 
(chapter  132,  Session  Laws  of  1911).  The  State  Board  of  Health 
regulations  provide  that  all  state  charitable  institutions  shall  be  in- 
spected annually.  But  there  is  no  provision  for  one  definite  board,  com- 
mission, or  other  central  authority  whose  specific  business  it  is  to  look 
after  all  institutions  and  societies  harboring  or  caring  for  dependent 
children.  As  a  result,  these  inspections  have  been  more  or  less  haphazard 
and  without  any  special  directed  effort  of  one  agency  whose  business  it 
is  to  see  that  such  inspections  have  been  followed  up,  and  that  such 
orders  as  may  have  been  issued  are  carried  out. 

Reports  of  inspections  of  children's  institutions  on  file  with  the  State 
Board  of  Health  are  the  best  possible  argument  for  the  need  of  a  strict 
license  and  supervision  over  all  homes  or  institutions,  public  or  private, 
harboring  children  or  defenseless  expectant  women.  Such  license  should 
provide  for  strict  inquiry  into  the  character  of  the  person  or  persons 
applying  for  the  license ;  evidence  of  the  need  or  demand  for  the  proposed 
type  of  home  or  institution;  strict  classification  of  inmates  as  to  what 
ages,  kinds  and  classes  of  inmates,  and  how  many  may  be  housed  in  a 
given  home,  and  for  such  other  requirements  as  may  be  necessary  to 
assure  helpless  women  and  children  decent  surroundings  and  scientific 
and  humane  care.  Specified  provisions  are  very  necessary  to  prevent 
persons  suffering  with  tuberculosis,  syphilis  and  other  communicable  dis- 
eases being  housed  with  children,  also  to  prevent  children  of  tender  age 
from  being  housed  with  confinement  cases,  or  with  aged  indigents,  insane, 
feeble-minded,  police  cases  and  other  improper  persons. 

The  license  should  provide  for  at  least  an  annual  or  semiannual  in- 
spection, and  for  such  further  inspections  as  may  be  necessary  by  reg- 
ularly salaried  trained  inspectors,  such  as  are  now  employed  by  the 
state  to  inspect  livestock,  hotels,  dairies  and  places  employing  labor.  It 
should  include  the  necessary  authority  to  issue  orders  and  provision  for 
carrying  them  out.  The  license  to  operate  an  institution  should  be  posted 
in  a  public  place  in  such  institution. 


160  Kansas  State  Board  of  Health. 

A  health  and  hygiene  license  provided  by  the  State  Board  of 
Health,  together  with  the  present  regulation  and  license  for  solicitation 
of  funds  by  the  Board  of  Administration,  will  give  a  valuable  double 
check  on  children's  institutions,  both  public  and  private.  With  such  regu- 
lation and  supervision  it  would  only  be  a  question  of  time  until  all  the 
better  institutions  could  be  strengthened  and  improved,  while  the  improper 
ones  could  be  made  to  clean  up  or  get  out  of  business. 


Women  and  Children  in  Industry. 

Because  of  the  maternal  functions,  the  protection  of  women  in  industry 
is  even  more  important  than  the  protection  of  men.  The  strain  of  con- 
tinuous standing,  bad  hygiene  and  overwork,  to  which  young  women  may 
be  subjected  in  stores  and  factories,  is  responsible  for  such  ill  health  as 
seriously  interferes  with  childbearing  functions.  Protection  of  women  in 
industry  is  necessary  not  only  to  safeguard  the  labor  supply,  but  to  con- 
serve the  nation's  human  resources. 

The  Kansas  Industrial  Welfare  Commission,  whose  powers  are  set 
out  in  Chapter  108,  General  Statutes  of  1915,  establishes  the  regulation 
of  hours,  wages  and  sanitary  conditions  of  women  and  children.  This 
Commission  has  made  regulations  governing  hours  and  wages  for  mer- 
cantile establishments,  laundries  and  telephone  companies.  Just  as  soon 
as  the  necessary  investigations  can  be  made,  the  Commission  will  establish 
regulations  covering  other  industries. 

While  the  hours  and  wages  for  women  vary  with  the  degree  of  skill 
necessary  to  the  occupation,  the  intent  of  the  Kansas  regulations  is  that 
women  and  minors  shall  be  paid  a  living  wage;  that  they  shall  not  work 
too  long  hours,  and  that  they  shall  work  in  sanitary  surroundings. 

In  the  process  of  the  Working  out  of  any  progressive  measure,  mis- 
understandings, minor  injustices  and  complaints  are  likely  to  arise;  also 
strenuous  opposition  from  those  who  profit  from  exploited  labor  will  be 
encountered.  The  rulings  of  the  Industrial  Commission  are  based  on  the 
theory  that  women  and  children  are  entitled  to  work  in  decently  clean 
surroundings  and  for  a  living  wage.  If  the  industry  cannot  afford  the 
cost  of  sanitary  surroundings  and  living  wages,  neither  can  Kansas  afford 
to  allow  her  women  and  children  to  be  used  up  to  supply  the  deficit. 


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